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LIBRARY 

OF  THK 

University  of  California. 

GIFT    OF 

Class 


MENTAL   PATHOLOGY 


AND 


THERAPEUTICS 


BY 


W.  GRIESINGER,  M.D., 


PROFESSOR  OF    CLINICAL   MEDICINE  AND  OF    MENTAL  SCIENCE  IN   THE  UNIVERSITY 
OF    BERLIN  ;    HONORARY  MEMBER    OF    THE    MEDICO-PSYCHOLOGICAL    ASSO- 
CIATION ;    MEMBRE    ASSOCIE    ETRANGER    DE    LA    SOCIETE     MKDICO- 
PSYCHOLOGIQUE  DE  PARIS;  ETC.,    ETC. 


TRANSLATED  FROM  THE  GERMAN  (SECOND  EDITION) 


BY 

C.    LOCKHART  ROBERTSON,    M.D.    Caktab., 

MEDICAI.  SUPKRINTKNDENT  OP  THE  SUSSEX  LUNATIC  ASYLUM  HATWARD's  HEATH  ; 

AND 

JAMES  RUTHERFORD,   M.D.   Edin.- 


NEW  YORK 
WILLIAM     WOOD    &    COMPANY 

1882 


BIOL-Lia. 


Copyright  by 
WILLIAM  WOOD  &  COMPANY. 

1882. 


STEAM   PRESS   OP 

H.  O.  A.  Industrial  School, 
187  &  189  E.  76th  St.,  New  York. 


N^OTE  BY  THE  TRANSLATORS. 


We  have  endeavored,  in  the  following  translation  of  the  second 
edition  of  Professor  Griesinger's  standard  work  on  'Mental  Pathology  and 
Therapeutics,'  to  give  the  English  reader  an  accurate  and  literal  rendering 
of  the  German  text.  In  thus  adhering  to  the  literal  meaning  of  the 
author,  we  have  followed  the  example  of  the  learned  translator  of  the 
French  edition'  of  this  work,  with  which  we  have  throughout  carefully 
compared  our  own  readings.  If  possible,  the  French  translation  renders 
Professor  Griesinger's  German  medico-metaphysics  (not  easily  understood 
even  in  German)  more  literally  than  we  have  done.  It  was  soon  evident 
to  us  that  any  attempts  at  a  more  liberal  rendering  of  these  difficulties 
would  only  farther  obscure — possibly  contravene — the  author's  meaning. 

Pkofessoe  Griesinger  is  essentially  the  representative  and  the  ac- 
knowledged leader  of  the  modern  German  school  of  Medical  Psychology. 
As  such,  his  work  must  be  an  object  of  deep  interest  to  every  student  in 

Mental  Science. 

C.  L.  E. 

J.  E. 
June  1,  1867. 

'  '  Traite  des  Maladies  Mentales,  pathologie  et  therapeutique,  par  le  Docteur 
W.  Griesinger,  etc.  etc.  Traduit  de  I'Allemand  (2e  edition)  sous  les  yeux  de 
I'Aiiteur,  par  le  Docteur  Doumic,  Medecin  de  la  Maison  centrale  de  Poissy.'    Paris, 

1865,  pp.  587. 


210798 


PREFACE  TO   THE   SEOO:ND  EDITIOjST. 


I  AM  happy  to  be  able  at  last  to  place  in  the  hands  of  the  profession 
the  long-delayed  second  edition  of  this  work.     It  is  not  entirely  a  new 
work,  many  chapters  remain  entirely  unaltered;  many  others,  however, 
have  undergone  correction  and  remodelling,  and,  in  particular,  great  ad- 
I  ditions  have  been  made,  which  I  hope  may  be  considered  as  adding  to  the 
value  of  the  work.     Fewest  changes  have  been  necessary  in  the  descrip- 
:  tion  of  the  special  forms  of  insanity:  melancholia,  mania,  dementia,  etc., 
i  have  indeed  remained  the  same  since  1815.     Most  alterations  and  addi- 
\  tions  occur  in  the  parts  relating  to  etiology,  pathological  anatomy,  the 
anatomy  of  the  brain,  the  psychological  introduction,  the  complications 
of  insanity,  and  treatment.    An  entirely  new  section  on  the  general  diag- 
nosis of  mental  disease  has  been  added,  and  also  a  section  on  idiocy  and 
cretinism.     This  subject  is  entirely  omitted  in  the  first  edition.     Since 
the  date  of  its  publication  I  have  had  occasion  and  opportunity  more  im- 
'  mediately  to  employ  myself  with  these  states  through  my  connection 
!  with  the  idiot  asylum  of  Mariaberg,  which  was  under  my  direction  during 
the  latter  period  of  my  residence  in  Wiirtemberg.     The  number  of  illus- 
I  trative  cases  have  been  increased  by  the  addition  of  several  interesting 
i  examples:  in  many  of  the  more  important  chapters  the  princii^al  litera- 
ture is  given  to  the  reader  who  desires  further  information;  finally,  I 
have,  as  often  as  opportunity  occurred,  sought  to  elucidate  the  medico- 
legal aspect  of  psychiatry  from  the  stand-point  of  the  doctrines  contained 
in  this  work,  and,  as  occasion  offered,  expressed  my  views  shortly  but 
distinctly  concerning  much  that  is  related  to  the  present  state  of  medical 
psychology.     In  this  I  had  solely  the  interests  of  science  aud  the  profit 
of  the  reader  in  view,  totally  regardless  of  the  censure  or  applause  of  this 
or  of  that  school. 

As,  to  my  great  joy,  the  first  edition  of  this  work  won  many  friends 
to  the  study  of  our  interesting  science,  I  hope  that  the  second  also  Aviil 
contribute  to  the  extension  of  psychological  knowledge,  and,  in  particu- 
lar, of  correct  views  upon  the  subject.  In  the  Universities  our  specialty 
is  still  far  too  much  ignored,  and  clinical  instruction  especially  is  as  yet 
nowhere  conducted  and  acknowledged  in  a  degree  corresponding  to  the 


VI  PREFACE    TO    THE    SECOND    EDITION. 

importance  of  the  subject.  I  liave  done  my  j^art.  In  Tubingen,  for  up- 
wards of  ten  years,  I  regularly  delivered  lectures  upon  medical  jisychology, 
in  conjunction  with  my  principal  subject,  and,  as  often  as  opportunity 
offered,  admitted  cases  of  mental  disease  into  my  clinique,  making  them, 
like  any  other  disease,  the  subjects  of  clinical  instruction  and  discussion. 
The  advantage  of  this  is  so  apparent  that  I  live  in  the  hope  that  very 
soon  the  establishment  of  regular  psychological  cliniques  will  become 
general.  It  is  through  these  that  the  proper  idea,  the  purely  medical, 
of  mental  disease,  conjoined,  however,  with  a  knowledge  of  the  morbid 
mental  symptoms,  can  first  receive  that  general  extension,  so  very  desir- 
able, whereby  mere  asylum  managers  can  no  longer  call  themselves  med- 
ical psychologists,  whereby  that  fantastical  bombast,  sounding  of  the 
spiritual  world,  which  is  still  sometimes  apparent  in  psychological  litera- 
ture, will  soon  give  way  to  temperate,  clear,  medical  observation. 

Several  of  the  most  recent  writers  on  insanity  have  been  so  well 
pleased  with  the  first  edition  of  my  book  that  they  have  assumed  into 
their  writings  not  only  the  ideas  and  doctrines,  the  arrangement  and  ex- 
ample scontained  in  it,  but  have  even  taken,  without  restraint,  as  their 
own,  simple  excerpts  of  whole  sections.  I  quietly  permitted  this  to  oc- 
cur, but  now  it  would,  of  course,  be  disagreeable  to  me  if  any  one  were 
to  think  that  it  was  I  who,  in  this  edition,  had  borrowed  from  those 
authors.  I  would  therefore  beg  of  the  reader,  wherever  doctrines,  pages, 
and  even  chapters,  occur  similar,  or  nearly  similar,  to  what  they  may 
shortly  before  have  read  in  books  or  journals,  simply  to  compare  them 
with  the  first  edition  of  this  Avork  which  appeared  in  1845. 

G. 


CONTENTS. 


BOOK  FIRST — GEI^EEAL. 

CHAPTER  I. 
On  the  Seat  of  Mental  Diseases  and  the  Blethod  of  their  Study 

CHAPTER  II. 
Preliminary  Anatomical  Observations  .  .  . 

CHAPTER  III. 
Preliminary  Physio- pathological  Observations  on  Mental  Phenomena 

CHAPTER  IV. 

Tlie  Elementary  Disorders  in  INIental  Disease     . 

I.  The  Elementary  Intellectual  Disorders 

A.  Anomalies  of  Sentiment 

B.  Anomalies  of  Thought 

a.  Formal  Deviations 

b.  Perversions  of  Thought — Delirioiis  Ideas 

c.  Anomalies  of  the  Will 

II.  The  Elementary  Disorders  of  Sensation 

III.  The  Elementary  Disorders  of  Movement 

CHAPTER  V. 

On  Insanity  in  General 

I.  The  Analogies  of  Insanity 

II.  The  General  Diagnosis  of  Mental  Disease 


PAGE 
1 


17 


43 
43 
45 
47 
47 
50 
53 
55 
73 


75 

75 
80 


/ 


BOOK   SECOI^D. 

THE    CAUSE    AND    MODE    OF    ORIGIN    OF    MENTAL    DISEASE. 

CHAPTER  I. 
The  Causes  of  Insanity  ...... 

CHAPTER  II. 

The  Predisposing  Causes  of  Mental  Disease        .... 

I.  General  Predisposing  Causes  .... 

II.  Special  Predisposing  Causes  .  .  •  • 


89 


94 
94 

106 


CHAPTER  in. 


The  Causes  of  Insanity  (continued) 

I.  Mode  of  Action  of  Causes 

II.  Psychical  Causes 

III.  Mixed  Causes 

IV.  Physical  Causes 


114 
114 
115 
119 
122 


Vlll 


CONTENTS. 


BOOK   THIED. 

FORMS    OF    MENTAL    DISEASE. 

CHAPTER  I.  PAGE 

States  of  Mental  Depression — Melancholia         ....        146 

I.  Hypochondriasis      ......        147 

II.  Melancholia  in  a  more  Limited  Sense  .  •  .156 

III.  Melancholia  with  Stupor     .  .  .  .  .172 

IV.  Melancholia  with  Destructive  Tendencies       .  .  .176 

A.  Melancholia  with  Suicidal  Tendencies      .  .  .        177 

B.  Melancholia  with  Destructive  and  Murderous  Tendencies    ,         183 
V.  Melancholia  with  Persistent  Excitement  of  the  Will      .  .        190 

CHAPTER  II.  j 

States  of  Mental  Exaltation    .  .  .  .  .  .192 

I.  Mania  .  .  .  .  .  .  .195 

II.  Monomania  ......        2V6 

CHAPTER  HI. 

The  States  of  Mental  Weakness  .  .  .  ^  ^ .  .225 

I.  Chronic  Mania  (Die  Verriicktheit ;  La  Folie  svstematisee)  .        228 

II.  Dementia  .  .  .  "   .  .  .240 

III.  Apathetic  Dementia  .....        242 

IV.  Idiocy  and  Cretinism  .  .  ,  •  .        244 

A.  Idiocy  in  general  .....        245 

B.  Endemic  Cretinism       .....        253 

CHAPTER  IV. 
On  several  Important  Complications  of  Insanity  .  i  •        277 


BOOK  rOUBTH. 

THE    PATHOLOGICAL    ANATOMY    OF    MENTAL    DISEASE. 

CHAPTER  I. 


Pathological  Anatomy  of  the  Brain  and  its  Membranes 

290 

A.  The  Cranium                  .... 

294 

B.  The  Arachnoid               .... 

296 

C.  The  Pia  Mater  and  Surface  of  the  Brain                  . 

298 

D.  The  Cerebral  Substance               .                .               • 

300 

E.  The  Ventricles  and  Internal  Parts             .               • 

303 

I.  Acute  Insanitj^          .                .                .                .               « 

306 

II.  Chronic  Insanity     ..... 

306 

III.  Paralytic  Dementia              .... 

307 

CHAPTER  II. 

The  Pathological  Anatomy  of  other  Organs       .                .               • 

309 

BOOK    FIFTH. 

THE    PROGNOSIS    AND    TREATMENT    OF    MENTAL    DISEAS 

5E. 

CHAPTER  I. 

Prognosis                   ...... 

317 

CHAPTER  II. 

Therapeutics            ....... 

326 

I.  General  Principles                   .               .               .               .               . 

326 

II.  Physical  Treatment                .               .                .                .                . 

333 

III.  Moral  Treatment  ...... 

342 

rV.  Various  Modifications  of  Treatment 

351 

V.  Lrmatic  Asylums    ..... 

358 

Indkx         ........ 

371 

ON 


MENTAL    DISEASES. 


BOOK  FIEST-GEI^5"EEAL. 


CHAPTER  I. 


ON  THE  SEAT  OF  MENTAL  DISEASES  AND  THE  METHOD 

OF  THEIR  STUDY. 

§  1.  The  following  treatise  has  for  its  object  the  study  of  mental 
disease  or  insanity,  its  diagnosis  and  treatment.  Insanity  itself,  an  ano- 
malous condition  of  the  faculties  of  knowledge  and  of  will,  is  only  a 
symptom;  our  classification  of  the  group  of  mental  diseases  proceeds  upon 
the  symptomatological  method,  and  by  such  a  method  alone  can  any 
classification  be  effected.  The  first  step  towards  a  knowledge  of  the 
symptoms  is  their  locality — to  which  organ  do  the  indications  of  the 
disease  belong?  what  organ  must  necessarily  and  invariably  be  diseased 
where  there  is  madness?  The  answer  to  these  questions  is  preliminary  to 
all  advancement  in  the  study  of  mental  disease. 

Physiological  and  pathological  facts  show  us  that  this  organ  can  only 
be  the  brain;  we  tlierefore  primarily,  and  in  every  case  of  mental  disease, 
recognize  a  morbid  action  of  that  organ. 

§  2.  Physiology  considers  mental  activity  as  a  special  form  of  organic 
life;  it  recognizes  in  mental  energy  the  function  of  a  particular  organ, 
and  attempts  to  deduce  it  from  the  physical  organism.  Well-known  ex- 
periments prove  that  if  the  mental  faculties,  in  the  wide  sense  of  the  term, 
are  related  to  the  whole  nervous  system,  the  seat  of  intelligence  and  of  vo- 
lition is  in  the  brain,  and  confined  to  certain  portions  of  it.  Of  course, 
the  spinal  cord,  as  also  the  ganglionic  system  of  the  sympathetic,  possess 
not  only  functions  of  transmission,  but  also  central  functions  of  commu- 
nication, of  association,  and  of  excitation  (tonicity,  reflex  action,  etc.), 
but  relatively  to  the  higher  central  functions  theirs  is  merely  peripheral. 
The  states  of  any  part  of  the  nervous  system,  inasmuch  as  they  are  trans- 
mitted to  the  brain,  also  furnish  matter  of  mental  excitation  and  Intel-, 
lectual  activity.  Impressions  can  originate  from  every  peripheral  nervous 
ramification  which  may  prompt  to  motives,  and  originate  obscure  or  well- 
defined  conceptions  and  efforts;  but  it  is  the  brain  alone  which  receives 
and  concentrates  these  impressions,  and  which  originates  the  influences 


2  THE    SEAT    OF    MENTAL    DISEASES 

exerted  by  them  upon  series  of  co-ordinate  movements — that  is,  upon  the 
actions. 

The  deeper  actions  of  the  understanding  and  will  can  no  more  be  de- 
duced from  the  organization  of  the  brain  than  those  of  sensation.  Never- 
theless, the  successive  acts  of  the  mental  faculties  can,  in  a  general 
manner,  be  easily  referred  to  the  structure  of  the  different  parts  con- 
cerned. That  portion  of  the  central  nervous  system  within  the  cranium 
consists  of  masses  of  nerve-substance.  These  receive  the  sensitive 
columns  of  the  spinal  marrow,  and  the  central  expansions  of  the  higher 
nerves  of  sense;  from  this  again  the  motory  columns  of  the  marrow  pro- 
ceed. In  accordance  Avith  this,  we  see  that  all  impressions  occurring 
centripetally,  through  the  senses,  converge  in  the  brain,  are  perceived, 
assimilated,  and  excite  the  mental  faculties,  and  then  give  rise  to  new 
centrifugal  acts,  owing  to  the  relation  in  which  sense  and  mind  stand  to 
the  actions  of  the  motory  system. 

We  see  that  in  the  animal  species  the  psychical  powers  are  varied,  and 
capable  of  high  development,  in  proportion  to  the  size,  the  quality,  and 
the  form  of  the  brain;  in  short,  according  to  the  volume  of  the  great 
hemispheres.  So  also,  in  the  human  race,  we  observe  that  great  defi- 
ciency of  cerebral  development  is  attended  by  weakness  of  the  mental 
faculties,  of  the  intellect  and  will  (in  many  cases  of  idiocy);  and  experi- 
ence teaches,  that  in  all  men  these  faculties  materially  alter  with  the  de- 
gree of  development,  and  tlie  changes  which  the  brain  presents,  at  the 
different  stages  of  life.  Even  in  these  changes,  these  successive  steps  of 
gradual  progress  in  maturity  and  decline,  thementalcapacity  of  the  brain 
runs  parallel  with  all  the  other  organic  functions,  and  thus  proves  itself 
liable  to  the  same  laws  of  organic  development 

As  is  well  known,  it  has  been  already  attempted  to  refer  certain  phases 
of  mental  activity  to  other  parts  of  the  nervous  system  than  the  brain :  for 
instance,  feeUng  has  been  referred  to  the  nervus  sympatheticus.  From  a 
psychological  point  of  view,  this  attempt  sprang  from  the  sufficiently  refuted 
assumption  of  the  isolated  character  of  the  mental  faculties.  From  the  physio- 
pathological  point  of  view,  it  stands  in  opposition  to  all  we  can  positively  declare 
respecting  the  functions  of  the  sympathetic  nerve.  Quite  as  unfounded,  and 
equally  unexpounded,  is  that  doctrine  which  assumes  an  immediate  co-oper- 
ation of  all  parts  of  the  organism,  therefore  of  the  bones,  glands,  etc.,  with  the 
mental  functions,  and  would,  accordingly,  deduce  insanity  immediately  from 
disturbance  of  these  peripheral  organs.  .  ,     ,  , 

In  recent  times,  in  consequence  of  very  interestmg  results  furnished  by 
experiment,  essentially  psychical  functions,  sensation,  and  even  volition,  have 
been  ascribed  to  the  spinal  marrow  (Pfliiger,  Aurbach).  Schiff  ('  Physiol,  des 
Nervensystems,'  i.,  p.  211)  has  clearly  and  conclusively  elucidated  these  views,  as 
well  from  the  experimental  as  from  the  psychological  stand-point.  It  may  readily 
be  admitted  that  the  impressions  are  produced  in  the  spinal  marrow,  generally 
after  the  same  scheme  as  in  the  brain  ;  and  it  cannot  easily  be  directly  refuted, 
that  in  the  spinal  marrow  of  the  frog,  sensation,  and  even  pain,  still  remain  after 
decapitation  ;  but  as  regards  ivill  (in  the  ordinary  sense  of  the  word)  it  cannot  be 
supposed  to  be  here  in  question,  for  the  will  implies  sensations,  which  have 
entered  the  sphere  of  consciousness,  along  with  the  idea  of  the  effort  which  pro- 
duces movement,  of  space,  of  the  limits  of  body— acts  for  the  accomplishment  of 
which  the  co-operation  of  the  central  sphere  of  the  sense  of  sight  is  absolutely 
necessary.  Very  recently,  Ffiuger's  theory,  founded  upon  his  experimental 
data,  has  also  been  caUed  in  question  (Goltz,  'Konigsb.  Med.  Jahrbuch.'ii.,  1860, 
p.  189). 

§  3.  Pathology  proves  as  clearly  as  physiology,  that  the  brain  alone 
can  be  the  seat  of  normal  and  abnormal  mental  action;  that  the  normal 
state  of  the  mental  process  depends  upon  the  integrity  of  this  organ;  and 


AND    THEIK    METHOD    OF   STUDY.        •  3 

that  both  together  are  influenced  by  the  state  of  the  other  organs  in 
disease.  The  invariable  and  essential  symptoms  of  cerebral  diseases  may 
arise  from  internal  causes  or  external  lesions;  may  proceed  from  anomalies 
of  sensation  and  movement,  and,  in  serious  diseases,  even  from  mental 
disturbance  (exaltation  or  depression  of  the  ideality,  loss  of  self -conscious- 
ness, delirium,  etc).  Cases  of  less  frequent  occurrence,  Avhere,  with 
serious  disorganization  of  the  brain  and  loss  of  brain-substance,  no  dis- 
turbance of  the  mind  is  apparent,  do  not  invalidate  the  results  of  our 
everyday  experience. 

Collections  of  such  cases  are  to  be  found,  as  in  Longet  (Anat.  et  Physiol,  d. 
Syst.  nerv.,'  Paris,  1842,  i.,  p.  670).  With  reference  to  most  of  these  and  other 
similar  cases  with  which  we  are  acquainted,  different  opinions  may  be  held.  In 
almost  all,  intelligence,  in  the  narrow  sense  of  the  word,  is  alone  considered; 
the  circumstances  of  disposition  and  will  are  entirely  overlooked;  and  even  to 
the  intelligence  but  slight  tests  are  applied  to  prove  its  integrity,  such  as  the 
answering  of  simple  medical  questions.  In  none  of  these  observations  has  the 
intelligence  been  tested  in  its  full  extent,  and  in  many,  particularly  in  all 
liospital  cases,  a  comparison  of  the  mental  condition  after  the  disease  or  loss  of 
substance  with  the  earlier  state  was  absolutely  impossible.  All  nicer  distinctions, 
therefore,  cannot  be  considered.  Notwithstanding,  it  must  be  admitted  that 
there  may  be  disease  and  loss  of  brain,  and  yet  no  appreciable  disturbance  of  the 
mental  life.  Very  much  depends  upon  the  seat  of  the  disease ;  all  parts  of  the 
brain  do  not  stand  in  the  same  close  relation  to  the  mental  functions ;  some  stand 
much  more  in  relation  to  muscular  movement  (Pons,  Thalami,  etc.).  Further, 
with  the  brain,  as  with  all  other  bilateral  organs,  it  is  highly  probable  that  a 
compensation  is  made  by  the  remaining  healthy  half  (see  §  15).  Lastly,  we 
frequently  find  limited  anatomical  lesions  in  other  important  organs  without  any 
striking  functional  derangement  (chronic  gastric  ulcer,  pleuritic  adhesions, 
tubercle,  etc.);  and  loss  of  substance  (through  gangrene)  has  likewise  been 
observed,  as  in  the  lungs  or  in  the  bowels,  where,  after  recoveiy,  the  process  of 
respiration  or  of  digestion  proceeded  without  apparent  interruption.  Such  facts, 
however,  would  not  readily  be  admitted  in  opposition  to  the  tenet,  that  the  lungs 
are  the  organs  of  respiration,  and  that  digestion  takes  place  in  the  bowels. 

Further  and  more  apposite  testimony  in  favor  of  our  assertion,  that 
the  brain  is  the  organ  affected  in  insanity,  is  furnished  by  examination  of 
the  bodies  of  the  insane  after  death.  In  many  such  examinations,  true 
anatomical  changes  are  found  in  the  brain  itself,  or  in  its  coverings;  and 
where  anatomical  changes  exist  those  of  the  brain  are,  at  least,  the  only 
constant.  The  circumstance  that  such  changes  are  not  always  found 
should  not  weaken  this  argument.  In  those  affections  of  the  nervous  sys- 
tem which  are  chiefly  indicated  by  states  of  irritation,  as  neuralgias, 
cramps,  etc.,  we  very  frequently  find  no  appreciable  anatomical  lesion; 
ind  this  is  still  more  the  case  in  the  conditions  of  weakness,  paralysis,  etc. 
Very  many  mental  diseases  belong  to  the  first  of  these  two  classes.  It  is 
with  this  class  of  mental  diseases  as  with  a  number  of  other  nervous  af- 
fections, as  epilepsy,  tetanus,  etc.,  whose  seat  is  in  the  brain  or  spinal 
marrow;  and  although  in  many  cases  this  cannot  be  ocularly  demonstrated 
by  pathological  anatomy,  still,  on  physiological  grounds  it  is  universally 
admitted. 

The  majority,  however,  of  the  mentally  diseased,  besides  disturbances 
of  the  intellect  and  will,  present  remarkable  anomalies  of  other  functions 
which  doubtless  belong  also  to  the  brain;  above  all,  hallucinations,  ano- 
malies of  sensation,  whicli  in  many  cases  are  felt  to  be  peripheral,  but 
whose  origin  must  necessarily  be  in  the  brain,  as  is  irrefutably  demon- 
strated by  Esquirol's  cases  of  permanent  hallucinations  of  sight  with  com- 
plete blindness  from  atrophy  of  the  optic  nerve.  We  see,  too,  that  the 
central  excitation  of  voluntary  muscles,  which  is  incontestably  a  cerebral 


4:  THE    SEAT    OF    MENTAL    DISEASES 

function,  is  altered  in  the  cases  of  many  who  are  mentally  diseased :  some- 
times it  assumes  the  forms  of  exalted  activity  and  energy,  sometimes  of 
cataleptic  rigidity;  at  others  it  is  seen  as  that  form  of  paralysis  whose 
rapid  progress  accompanies  the  course  of  a  certain  form  of  insanity  (de- 
mentia). Besides,  many  other  anomalies  of  cerebral  function,  as  lessened 
sensibility  to  pain  and  temperature,  sleeplessness,  convulsions,  cerebral 
congestion,  etc.,  are  observed  in  the  insane  more  as  accessory  symptoms; 
which,  however,  may  serve  further  to  confirm  the  existence  of  disease  in 
the  brain. 

While,  at  all  events  at  the  time  of  the  first  edition  of  this  book,  many  physi- 
cians, indeed  wliole  psychological  schools,  still  require  absolute  proof  of  the 
concluding  sentence  of  §  1,  many  of  the  more  eminent  psychologists  long  ago 
came  to  the  same  correct  conclusion,  tliat  in  every  mental  disease  the  brain  is. 
affected,  and  that  this  cerebral  affection  is  the  proximate  cause  of  the  insanity. 
(See  Stiedenroth,  '  Psychologie,'  ii.,  p.  278.) 

§  4.   While  we  are  forced  by  facts  to  refer  understanding  and  will  to 
r    the  "brain,  still,  however,  nothing  can  be  assumed  as  to  the  relation  exist- 
ing between  these  mental  acts  and  the  brain,  the  relation  of  soul  to 
material.     From  an  empirical  point  of  view  the  unity  of  soul  and  body 
is  indeed  a  fact  primarily  to  be  maintained,  and  the  a  priori  investiga- 
tion of  the  possibility  of  soul  apart  from  body,  of  a  bodiless  soul,  must 
be  entirely  dismissed,  confining  ourselves  to  abstract  considerations  of 
its  unity  and  oneness  as  distinguished  from  the  endless  modifications  of 
matter.     But  these  hypotheses  that  have  been  framed  to  render  more 
conceivable  the  otherwise  inexplicable  unity  of  soul  and  body,  by  means 
of  attenuated  fluids    which    mediate  between   them,    "   fluids   subtle 
enough  to  be  reckoned  spirit,"  even  by  the  system  of  pre-established 
harmony  according  to  which  body  and  soul  never  act  on,  but  always 
along  with,  one  another, — these  hypotheses  are,  empirically  considered, 
as  difficult  to  sustain  as  to  refute.     How  a  material  physical  act  in  the 
nerve  fibres  or  cells  can  be  converted  into  an  idea,  an  act  of  conscious- 
ness, is  absolutely  incomprehensible  ;  indeed,  we  are  utterly  unable  even 
to  settle  the  question  of  the  existence  or  nature  of  the  media  existing 
between  them.     All  these  matters  are  as  yet  only  probable ;  in  wliich 
state  of  affairs  the  simplest  hypothesis  is  the  best;  and  certainly  the 
materialistic  offers  fewer  difficulties,  obscurities,  and  contradictions  than 
any  other,  especially  in  relation  to  the  origin  of  thought._     Therefore, 
leaving  out  of  view  those  possible  but  quite  unknown  mediating  events, 
it  is  scientifically  admissible  to  connect  the  faculties  of  the  soul  with  the 
body  in  the  same  intimate  relation  as  exists  between  function  and  organ 
— to  consider  the  understanding  and  the  will  as  the  function,  tlie  special 
energy,  of  the  brain,  just  as  transmission  and  reflex  action  are  considered 
the  special  functions  of  the  nerves  and  spinal  cord,  and  to  consider  the 
soul  primarily  and  pre-eminently  as  the  sum  of  all  cerebral  states. 

Definite  information  regarding  v^hat  takes  place  in  the  soul  can  neither  be 
afforded  by  materialism,  which  would  explain  all  mental  acts  by  the  pliysical, 
nor  by  spiritualism,  which  would  explain  the  material  by  the  psychical.  And 
even  if  we  did  know  all  that  takes  place  within  the  brain  when  in  action—if  we 
could  penetrate  into  all  the  processes,  chemical,  electrical,  etc.,  of  what  use  is  it? 
Oscillation  and  vibration,  all  that  is  electrical  and  mechanical,  are  still  not  mental 
conditions,  acts  of  thought.  How  they  can  be  transformed  to  these  is,  indeed,  a 
problem  which  shall  remain  unsolved  to  the  end  of  time ;  and  I  believe  that  if 
to-day  an  angel  from  heaven  came  and  explained  all  to  us,  our  understanding 
would  not  even  be  able  to  comprehend  it. 

What  shall  now  be  said  of  the  flat  and  shallow  materialism  which  would 
overturn  the  most  general  and  most  valuable  facts  of  human  consciousness 


AND    THEIR    METHOD    OF    STUDY.  5 

because  it  finds  no  palpable  trace  of  them  in  the  brain?  Empirical  perception, 
in  asciibing  the  phenomena  of  sensation,  intellect,  and  will  to  the  brain  as  its 
function,  leaves  not  only  the  actual  contents  of  the  life  of  the  human  soul 
untouched  in  all  its  riches,  and,  in  particular,  maintanis  energetically  the  fact  of 
free  self-determination;  it  leaves  also,  naturally,  the  metaphysical  question, 
what  it  may  be  that  enters  as  soul-substance  in  this  relation  of  the  sensation, 
understanding,  and  will,  which  takes  the  form  of  psychical  existence,  etc. 
Empiricism  must  patiently  await  the  time  when  the  questions  concerning  the 
connection  of  the  contents  of  the  life  of  the  human  soul,  with  its  forms,  shall 
have  become  physiological  instead  of  metaphysical  problems.  Meanwhile,  would 
tliey  but  desist  from  the  pursuit  of  unanswerable  questions,  from  striving  wildly 
in  science,  and  from  accusing  each  other  of  heresy  by  the  mixing  up  of  quite 
heterogeneous  questions.  Would  the  followers  and  fanatics  of  materialisnr  but 
consider  a  point  wliich  appears  to  me  not  to  have  been  hitherto  sufficiently 
brought  forward  in  the  discussions  of  these  questions.  The  elementary  phenom- 
ena wiiich  occur  in  the  nerve-masses  must  be  in  all  men  always  identical, 
especially  if  they  be  considered  (as  is  now  believed  by  many)  as  essentially  elec- 
trical, necessarily  in  the  highest  degree  simple,  consisting  of  4-  and  — .  How  "^ 
could  the  endless  variety  of  thoughts,  feelings,  and  desires,  not  only  of  individual 
men,  but  of  different  ages,  proceed  from  these  alone  and  immediately  ? 

Any  discussion  concerning  the  materiality  or  immateriality  of  the  mental 
processes  cannot,  therefore,  in  the  present  state  of  our  knowledge,  be  decided; 
it  would  fall  in  part,  and  already  in  its  first  premises,  together  with  the  question 
of  the  internal  changes  in  the  activity  of  the  nervous  system.  All  comparison 
with  the  imponderables,  which  stand  in  a  relation  analogous  to  matter,  and 
appear  also  as  somewhat  immaterial,  provoke  however  material  changes  and 
modifications,  are  of  but  little  service.  The  mental  or  nervous  agent  has  no  real 
analogue  in  the  whole  of  the  universe;  the  theory,  as  Locke  has  already  shown, 
experiences  the  same  difficulties,  whether  they  allow  to  think  the  material,  or 
whether  they  will  comprehend  the  action  of  an  immateiial  agent  upon  matter. 
That  the  functions  of  the  soul,  moreover,  must  alwaj's  be  accompanied  by 
material  acts,  no  one  denies;  this  relation  is  very  well  developed  by  Stiedenroth 
(i.,  p.  53,  and  a.  a  O.);  only  the  idea  which  participates  in  the  organic  accompani- 
ment is  to  him  a  real,  and  known,  and — a  still  more  fruitful  proposition! — indeed, 
the  more  lively  the  organic  accompaniment,  the  livelier  the  thought.  Some 
phases  of  the  mental  processes  are,  moreover,  evidently  more  closely  associated 
with  so-called  physical  events  (with  other  acts  of  the  organism)  than  others;  for 
example,  than  pure  and  calm  thought.  Memory  and  love,  says  Aristotle  (On  the 
Soul,'  i.,  4),  do  not  proceed  from  the  soul,  but  from  the  association  of  the  soul  and 
the  body.  Indeed,  it  is  in  memory  and  in  love  that  a  direct  mixture  of  organic 
processes  is  most  evident ;  the  same  may  also  be  said  of  the  imagination. 

§  5.  lu  accordance  with  the  foregoing  statements,  the  question  so 
frequently  and  so  largely  treated  of  by  the  earlier  psychologists,  whether 
insanity,  in  the  anomalies  of  the  understanding  and  will,  the  disease 
really  affects  the  soul,  finds  a  ready  and  an  affirmative  solution.  Of 
course  we  must  not  speak  of  diseases  of  the  soul  alone — a  pathology  not 
less  incorrect  speaks  of  diseases  of  the  vital  processes,  of  the  functions — 
but  of  disease  of  the  brain,  through  which  every  act  of  the  intelligence 
and  the  will  is  deranged. 

§  6.  Although,  however,  every  mental  disease  proceeds  from  an 
affection  of  the  bi'ain,  every  disease  of  the  brain  does  not,  on  that  account, 
belong  to  the  class  of  mental  diseases.  What  kind  of  brain  affection, 
then,  is  it  with  which  we  hav^e  to  do  in  insanity?  Anatomically  con- 
sidered, the  diseases  whose  symptoms  are  called  insanity  are  of  all  the 
most  diverse,  simple  irritations  without  perceptible  changes  of  structure, 
inflammation  of  the  cortical  substance,  atrophy,  changes  of  nutrition, 
anomalies  of  the  circulation  within  the  cranium,  intra-meningeal  aj)o- 
plexy,  simple  hyperaemias  of  the  brain,  etc.  All  these  conditions,  differing 
so  widely  from  each  other,  can  originate  sym])toms  on  account  of  whicli 
we  send  the  patient  to  an  asylum,  and  which  are  described  in  psycholog- 
ical works  as  mental  diseases.    All  attempts  strictly  to  distinguish  insau- 


6  THE    SEAT   OF    MENTAL   DISEASES 

ity  from  the  acute  or  chronic  diseases  of  the  brain,  as  they  are  described 
from  the  anatomical  point  of  view — for  example,  meningitis,  encepha- 
litis, etc. — would  be  an  undertaking  most  futile,  for  even  certain  cases  of 
mental  disease  are  really  meningitis,  encephalitis,  etc.  The  idea  of 
mental  diseases  being  purely  symptomatological  in  great  measure  accom- 
panies these  anatomical  notions,  and  the  objects  of  both  do  not  admit  of 
their  being  compared  with  each  other.  Only  this  much  can  in  general 
be  with  certainty  affirmed,  that  the  brain  affections  which  lie  at  tlie  root 
of  mental  diseases  are  infinitely  more  frequently  diffuse  than  localized.' 

Cerebral  pathology  is,  even  in  the  present  day,  to  a  great  extent  in 
the  same  state  which  the  pathology  of  the  thoracic  organs  was  in  before 
the  days  of  Laennec.  Instead  of  proceeding  in  every  case  from  the 
changes  of  structure  of  the  organ,  and  being  able  to  deduce  in  an  exact 
manner  the  production  of  the  symptoms  from  the  changes  in  the  tissue,  it 
has  very  often  to  deal  with  symptoms  of  which  it  can  scarcely  give  an  ap- 
proximation to  the  seat,  and  of  whose  mode  of  origin  it  is  totally  ignorant. 
It  must  keep  to  the  external  phenomena,  and  establish  the  groups  of  dis- 
eases according  to  something  common  and  characteristic  in  the  symptoms 
altogether  independently  of  their  anatomical  basis.  As  with  epilepsy, 
chorea,  etc.,  so  also  with  psychical  or  mental  diseases,  under  which  we 
include  all  those  affections  of  the  brain  in  which  anomalies,  derangements 
of  the  understanding  and  of  the  will,  constitute  the  most  striking 
symptoms. 

The  ordinary  diseases  of  the  brain,  circumscribed  inflammation,  abscesses, 
tumors,  tubercular  meningitis,  etc.,  are  not  termed  mental  diseases,  even 
although  in  these  affections  the  mental  faculties  are  usually  more  or  less- 
deranged,  because  other  cerebral  symptoms,  those  of  disturbed  sensation  and 
movement  in  general,  greatly  predominate:  a  potiori  Jit  denominatio. 

Exceptionally,  however,  such  patients  are  also  considered  as  mentally 
diseased,  and  are  sent  into  asylums,  when,  for  example,  the  case  assumes  from 
the  first  the  chronic  form,  when  maniacal  excitement  sets  in  very  early,  etc.  On 
the  other  hand,  in  mental  diseases  the  sensitive  and  motory  functions  of  the 
brain  are  very  commonly  also  disturbed;  but  this  disturbance  is  subordinate, — 
the  psychical  appear  as  the  leading  phenomena.  More  minute  definitions  of 
mental  diseases  cannot  and  need  not  be  given  here;  their  general  diagnosis  will 
be  found  in  the  2d  section,  chapter  5th  of  this  book. 

§  7.  As  insanity  is  only  a  complication  of  symptoms  of  various  morbid 
states  of  the  brain,  the  question  might  be  asked,  whether  its  special  study 
apart  from  that  of  the  other  diseases  of  the  brain  can  be  justified,  or 
whether  mental  pathology  should  not  rather  always  accompany  cerebral 
pathology?  But,  although  at  some  more  distant  period  this  may  perhaps 
be  looked  for,  any  attempt  at  such  a  combination  would  at  present  be 
premature  and  quite  impracticable.  If  the  intimate  fundamental  union 
which  exists  between  insanity  and  the  other  cerebral  diseases  be  only 
constantly  kept  in  view, — if  in  the  one,  as  in  the  other  group,  the  same 
exact  anatomical  physiological  method  be  as  far  as  possible  pursued, — 
cerebral  pathology  will  not  be  retarded,  but  rather  advanced,  by  the 
formal  specializing  and  monographical  elaboration  of  these  diseases  classi- 
fied according  to  their  symptoms.  As  psychiatric  must  assert  the  posi- 
tion so  lately  obtained  for  it — as  a  part  of  cerebral  pathology,  and  as 
several  of  its  practical  phases,  asylum  economy,  its  medico-legal  bearings, 
etc.,  invest  it  with  an  extent  and  character  peculiar  to  itself,  which  under 
all  circumstances,  even  when  viewed  as  a  part  of  cerebral  pathology,  keep 

'  See  "  The  Diagnosis  of  Brain  Diseases,"  a  paper  by  the  author,  '  Archiv  der 
Heilkunde,'  Leipzig,  1860,  part  i.,  p.  51. 


AND    THEIR    METHOD    OF    STUDY.  < 

it  distinct,  any  attempt  to  obliterate  that  distinction  would  at  present  be 
still  less  justifiable. 

The  earlier  attempts  completely  to  combine  the  mental  diseases,  based  upon 
their  corresponding  anatomical  changes,  with  the  cerebral  diseases,  were  proved 
by  their  want  of  success  to  be  premature  and  impossible  (Sc.  Pinel,  '  Pathologie 
cerebrale,'  Paris,  1844).  And  just  as  when,  quite  recently,  one  of  our  most 
eminent  physicians  attempted  to  study  a  department  of  mental  diseases  from  a 
purely  anatomical  point  of  view  (Calmeil,  '  Traite  des  Maladies  inflammatoires 
du  Cerveau,'  Paris,  1859,  2  vol.),  so  this  praiseworthy  attempt  treats,  from  the 
nature  of  the  question,  only  of  a  part  of  these  conditions.  Thus  psychiatrie 
will  long  remain  a  special  branch  of  medical  science  ;  its  special  study  also  gives 
to  the  physician  opportunity  to  acquaint  himself,  in  some  degree  at  least,  with 
the  phenomena  of  mind  of  which,  unfortunately,  so  little  knowledge  is  in  general 
attained  in  the  ordinary  course  of  medical  study. 

§  8.  Insanity  being  a  disease/  and  that  disease  being  an  affection  of 
tlie  brain,  it  can  therefore  only  be  studied  in  a  proper  manner  from  the 
medical  point  of  view.  The  anatomy,  physiology,  and  pathology  of  the 
nervous  system,  and  the  whole  range  of  special  pathology  and  thera- 
peutics, constitute  preliminary  knowledge  most  essential  to  the  medical 
psychologist.  All  non-medical,  more  particularly  all  poetical,  and  ideal 
conceptions  of  insanity  are  as  regards  its  study  of  the  smallest  value. 
Several  poetical  representations  of  madness  are  excellent  in  certain  points, 
and  evidently  drawn  from  a  study  of  nature  (as  Ophelia,  King  Lear,  and 
particularly  Don  Quixote);  but,  as  the  poet  has  almost  entirely  evaded 
the  organic  causes  of  these  states,  looking  only  to  the  intellectual  side, 
regarding  them  as  the  results  of  former  moral  conflicts,  and  only  requires 
to  bring  forward  that  which  serves  this  end,  his  delineation  is  at  least 
one-sided.  A  similar  reproach  is  applicable  to  the  manner  in  which  the 
moralists  consider  the  subject,  and  still  stronger,  on  account  of  the 
earnestness  with  which  some  such  attempts  appeared.  Nothing  is  more 
false,  nothing  is  more  opposed  to  everyday  observation,  than  any  attempt 
to  transpose  the  nature  of  the  mental  diseases  into  the  territory  of  mo- 
rality. Facts  speak  loud  enough,  it  is  true,  in  favor  of  a  very  frequent 
psychical  etiology  of  these  diseases;  how  can  it  be  otherwise  when  moral 
causes  are  amongst  the  weightiest,  and  most  frequent,  of  the  other  dis- 
eases of  the  brain  and  nervous  system.  The  present  state  of  the  under- 
standing and  will  is  essentially  dependent  upon,  and  is  indeed  to  a  great 
extent  the  necessary  result  of,  the  sum  of  all  the  previous  thoughts  and 
wishes,  and,  as  a  consequence,  the  intellectual  life  becomes  a  fruitful 
scource  of  the  causes  of  insanity.  But  whilst  the  sphere  of  morality  is 
contained  entirely  within  that  of  free  and  conscious  thought,  the  start- 
ing-points of  the  anomalous  mental  processes  to  which  these  cerebral 
diseases  give  rise  belong  to  quite  another  territory.  It  is  from  obscure 
perversions  of  the  inner  consciousness,  that  in  insanity  the  states  of  the 
mind  originally  emotional,  proceed;  and  where  these  have  given  birth 
to  a  perversion  of  the  judgment  and  inclinations  of  the  patient,  he  is 
already  in  a  state  where  the  first  condition  of  all  morality,  self -conscious- 
ness, the  power  of  deliberation,  of  choice,  are  wanting,  and  his  acts,  be 
they  what  they  may,  can  no  more  be  the  object  of  a  moral  appreciation. 

Poetical  and  rhetorical  representations  of  insanity  are  not  only  unnecessary  and 
false  theoretically,  but  even  practically  they  are  positively  dangerous.  Through 
these  the  laity  are  filled  with  representations  of  mental  diseases  which  do  not  in 

'  A  disease  which  also  causes  death.  When  a  recent  writer  says,  lunatics  die 
as  little  from  insanity  as  other  men  from  soundness  of  mind,  he  tries  a  wretched 
antithesis.     It  is  evident  that  no  one  dies  frona  sound  health,  mental  or  bodily. 


8  THE    SEAT    OF    MENTAL    DISEASES. 

the  remotest  degree  resemble  nature:  if,  then,  the  facts  do  not  correspond  with 
their  ideas,  they  doubt  whether  mental  disease  be  present.  How  natural  is  the 
astonishment  of  many  persons,  when  visiting  an  asylum,  to  find  the  inmates  so 
very  different  from  what  they  expected!  Psychological  theories,  which  represent 
mental  diseases  as  the  highest  pitcli  of  the  passions,  lead  many  into  such  errors. 
Any  serious  controversy,  however,  regarding  the  moral  view  of  mental  dis- 
eases, is  nowadays  unnecessary.  It  would  be  even  superfluous  to  oppose  to  this 
doctrine  the  numerous  cases  where  insanity  is  produced  by  causes  purely  physical 
— by  injury  to  the  head,  by  narcotics,  etc. ;  its  hereditariness,  the  family  predis- 
position, often  showing  itself  in  other  relatives,  as  a  disposition  to  other  severe 
neuroses,  epilepsy,  hysteria,  etc. ;  its  various  types,  which  often  affect  the  course 
of  insanity  as  that  of  other  nervous  diseases;  its  occasionally  observed  interchange 
with  other  diseases,  the  possibility  of  rapid  cure,  its  analogy  with  dreams,  etc. 
The  best  refutation,  however,  is  the  simple  examination  of  the  progress  of  the 
symptoms  of  insanity. 


PKEUMINABY    ANATOMICAL    OBSERVATIONS.  9 


CHAPTER  11. 
PRELIMINARY    ANATOMICAL    OBSERVATIONS. 

§  9.  In  a  paper'  published  in  the  year  1844,  I  have  already  called  at- 
tention to  the  universally  demonstrable  pathological  analogy  which  exists 
between  the  diseases  of  the  brain;  also,  in  as  fur  as  they  present  by  pre- 
ference anomalous  mental  symptoms,  and  the  functional  disturbances, 
and  deeper  organic  lesions,  of  the  spinal  marrow.  This  comparison  is 
justified  not  only  by  the  facts  there  stated,  that  both  sections  of  the  cen- 
tral nervous  system  are  liable  to  the  same  forms  of  morbid  action,  which 
only  show  themselves  very  differently  according  to  the  originally  given 
difference  of  their  energies,  but  it  has  also  its  basis  in  the  normal  and 
pathological  anatomy,  which  teaches  us  to  recognize  in  the  brain  and 
spinal  cord  a  single,  only  artificially  divided,  whole,  and  exhibits  to  us, 
in  both,  the  same  general  dispositions,  the  same  elementary  tissues,  and 
also  the  very  same  pathological  changes. 

Presuming  that  the  reader  is  acquainted  with  the  general  anatomy, 
the  divisions  of  the  brain  and  spinal  cord,  the  structure  and  diposition 
of  their  membranes,  we  shall  here  premise  only  a  few  remarks  upon  the 
structure  and  connection  of  the  central  nervous  system,  which,  further 
on,  will  explain  certain  physio-pathological  results,  and  upon  the  review 
of  the  healthy  and  morbid  state  of  the  brain. 

§  10.  The  brain  and  spinal  cord  form  a  whole,  whose  different  sections 
present  essentially  the  same  elementary  structure,  and  a  common,  though 
constantly  progressing,  type  of  organization.'^ 

As  the  vertebrated  structure  of  the  bony  envelope  of  the  spinal  cord 
recurs  in  a  more  highly  developed  form  in  the  skull,  which  is  composed 
of  a  number  of  bones,  so  also  the  cranial  portion  of  the  central  nervous 
system  consists  of  a  complicated  multiplicity  of  nerve-masses,  which  at 
first  sight  appear  not  to  have  the  same  general  structure  as  the  spinal 
cord,  but  in  which,  nevertheless,  in  sjiite  of  many  important  differences, 
an  analogy  with  the  spinal  cord  and  its  immediate  envelopes  may  be 
recognized. 

The  central  canal  of  the  spinal  cord,  which  is  seen  most  distinctly  in 
the  embryo,  but  also  still  perceptibly  in  the  adult,  and  which  is  completely 
inclosed  by  gray  substance,  opens  at  the  level  of  the  fossa  of  the  ventricle 
of  Aurantius,  closes  again  at  the  fourth  ventricle,  and  forms  in  the  in- 
terior of  the  cerebrum  the  third  and  the  lateral  ventricles,  in  which  it 
terminates  in  the  infundibulum. 

The  gray  substance  of  the   spinal  cord  is  in  direct  commuuication 

'  '  Archiv  f,  physiolog.  Heilkunde,'  iii.,  1,  p.  69. 

*  Compare  Arnold,  '  Bemerkungen  ilber  den  Ban  des  Gehirns  und  Rticken- 
marks,'  Zurich,  1838.  Valentine,  '  Hirn-  und  Nervenlehre,'  Leipzig,  1841. 
Foville,  '  Anatomie  du  Systeme  nerveux  cerebro-spinal,'  Paris,  1844.  Longet, 
'  Anat.  et  Physiol,  d.  Syst.  nerv.,'  1843.  Buschke,  '  Schadel,  Gehirn  und  Seele,' 
Jena,  1854.  Gratiolet  (Leuret),  '  Anatomie  comparee  du  Syst.  nerveux,'  torn,  ii., 
Paris,  1857. 


10  PKELIMIKABY    ANATOMICAL    OBSERVATIONS. 

not  only  with  the  sensitive  and  motory  roots  of  the  nerves  whicli  pass  in 
and  out  of  it,  and  with  its  white  longitudinal  columns,  but  also  wiih  the 
gray  substance  of  the  brain.  After  it  has  extended  into  the  medulla  ob- 
longata, partly  upon  the  surface,  and  partly  by  entering  into  the  corpus 
iimbriatum  of  the  olivary  bodies,  and  into  the  corpora  restiforniia,  it 
communicates  with  the  corpus  rhomboideum  of  the  cerebellum;  then  in 
its  further  passage  forwards,  with  the  gray  substance  of  the  crura  cerebri, 
the  corpora  quadrigemina,  the  optic  thalamus,  and  corpus  striatum;  and 
ends,  at  last,  in  the  infundibulum  or  in  the  anterior  perforated  substance. 
The  continuation,  therefore,  of  the  gray  substance  of  the  spinal  cord  into 
the  interior  and  upon  the  base  of  the  brain,  forms  a  connected  system  of 
gray  lines  and  masses.  Another  system  of  gray  substance  is,  however, 
found  in  the  brain,  viz.,  the  cortical  substance  of  the  hemispheres, 
which  everywhere  covers  the  surface  of  the  convolutions  except  in  one 
point — the  gyi'us  fornicatus.  This  mass  of  gray  substance  communicates 
directly  with  the  first  system  in  only  one  point,  at  the  substantia  perfo- 
rata, and  this  connection  is  formed  through  the  medium  of  white  fibrous 
tracts;  in  the  spinal  cord  itself  it  has  nothing  analogous.  It  forms  the 
point  of  common  termination  for  the  system  of  the  extended  columns 
of  the  spinal  cord,  and  for  the  system  of  fibres  which  arises  within  the 
cranium  and  does  not  pass  out  of  it.- 

The  cortical  gray  substance  of  the  great  hemispheres  presents  a  strati- 
fied structure,'  and  consists  of  from  four  to  six  layers  of  substance  alter- 
nately opaque  and  transparent;  their  difference  depends  chiefly  upon  the 
greater  or  less  quantity  of  cell  elements  entering  into  their  composition. 
The  most  external  layer  is  in  direct  connection  Avitli  the  surface  of  the 
ventricles.  These  superficial  layers  of  the  cortical  substance  of  the  brain 
present  frequently  changes,  and  more  seldom  disorganization,  in  the  in- 
sane. The  minute  structure  of  this  substance  is  not  the  same  throughout 
It  is  composed,  fundamentally,  of  nerve  fibres,  whicli  proceed  from  the 
white  substance  and  in  entering  subdivide  until  they  become  very  fine  ; 
secondly,  of  peculiar  granules,  which  are  directly  connected  with  the 
ultimate  termination  of  these  fibres;  thirdly,  of  ganglion  cells,  which  are 
in  part  direct  prolongations  of  nerve  fibres,  or  continuations  of  the  gran- 
ules; fourthly,  of  an  apparently  homogeneous  and  structureless  molecular 
mass,  which  is  considered  by  some  as  cellular  tissue  having  a  purely  me- 
chanical function,  that  of  nerve  cement,  but  which,  at  least  in  the  corti- 
cal substance,  presents  an  extremely  fine  network  in  which  the  ultimate 
terminations  of  the  white  nerve  fibres  and  the  continuations  of  the  gran- 
ules are  finally  lost,  a  canalicular  tissue  communicating  on  all  sides, 
and  which  seems  to  conduct  to  every  part,  and  consequently  to  render 
possible  the  transmission  to  all  parts,  of  the  states  of  the  brain. 

As  these  elements  of  the  gray  substance  present  in  different  parts  of  this 
apparatus  a  different  arrangement,  the  inference  may  be  drawn  of  differences 
in  function.  Thus,  in  some  parts,  the  granules  form  a  special  and  im- 
portant layer  in  the  most  inferior  part  of  the  gray  substance  (in  the  corti- 
cal gray  substance  of  the  cerebellum  and  in  Amnion's  horn);  whilst  in 

Baillarger,  'Mem.  de  I'Acad,  de  Medecine,'  viii.,  1840,  p.  172.     Remak,  '  Miil- 
ler's  Archiv,'  1841. 

'^  Compare  Gerlach,  '  Microscopische  Studien,'  etc.,  Erlang.,  1858.  Hess,  '  De 
Cerebelli  Gyrorum  Structura,'  Dorp.,  1858.  BerHn,  '  Beitrage  z.  Structurlehre 
der  Grosshiruwiudungen,'  Erlang.,  1858.  C.  Kupffer,  '  De  Cornu  Ammonis 
Structura,'  Dorp.,  1859.  Stephany,  '  Beitrage  z.  Histologie  der  Rinde  des  grossen 
Gehirns,'  Dorp.,  1860. 


PRELIMINARY    ANATOMICAL    OBSERVATIONS.  11 

the  cortical  substance  of  the  cerebrum  they  do  not  form  a  special  layer, 
but  are  more  isolated.  Thus,  the  gray  substance  of  the  cerebellum  contains 
ciiielly  great  cells;  that  of  the  cerebrum,  on  the  contrary,  besides  a  num- 
ber of  large  cells,  contains  chiefly  small  ones  (Jacobowitch,  sensitive  cells): 
besides,  tliese  cells  are  sometimes  separated,  in  some  places  more  scat- 
tered, and  in  others  congregated  in  special  layers.  The  fine  fibres 
which  proceed  from  the  white  substance  extend  in  the  cerebellum  almost 
exclusively  to  the  most  inferior  layers  of  the  gray  substance;  in  the  cere- 
bral convolutions  they  penetrate  farther  into  it,  giving  ofE  fibrous  elements 
to  almost  all  its  layers,  and  they  here  appear  to  run  horizontally.  In 
some  places  the  axes  of  the  white  fibres  appear  to  pass  into  the  pro- 
longations of  the  ganglion  cells;  in  other  places  their  ultimate  termina- 
tion appears  to  be  in  the  granules  (cerebellum).  In  certain  parts  of  the 
gray  substance,  as  in  Ammon's  horn,  a  considerable  system  of  fibres 
appears  to  originate  in  the  thick  layers  of  cells  which  does  not  proceed 
farther  than  to  another  layer  of  the  same  substance  where  the  fibres  immedi- 
ately terminate.  Thus  the  relatively  little  which  we  as  yet  know  of  the 
intimate  structure  of  the  gray  substance  permits  us  to  suppose,  not  only 
very  great  differences  in  the  phenmoena  of  this  extremely  delicate_  appa- 
ratus, but  also  that  these  phenomena  are  essentially  different  in  the 
various  parts  of  the  brain. 

§  11.  The  white  substance  of  the  brain  is  composed  of  the  well- 
known  transparent  primitive  fibres;  in  general  they  are  here  very  fine; 
they  subdivide  many  times  within  it,  and  it  appears  afterwards  penetrate 
into  the  gray  substance,  which  contains  their  ultimate  divisions,  their 
points  of  termination  or  of  origin.  That  a  certain  portion  of  the  white 
substance  of  the  brain  is  formed  by  direct  continuations  of  the  three 
columns  of  the  spinal  cord  of  each  side,  which,  however,  undergo  a 
complete  process  of  decussation,  is  beyond  doubt:  for  example,  portions 
of  the  posterior  and  lateral  columns  can  be  easily  traced  into  the  cerebel- 
lum, portions  of  the  anterior  columns  into  the  corpora  quadrigemina, 
the  corpus  callosum,  etc.  ;  and,  according  to  undisputed  researches, 
it  is  admitted  that  continuations  of  all  three  columns  of  the  spinal 
cord  enter  into  each  of  the  great  ganglion- like  enlargements  which 
constitute  the  brain.  It  is  evident,  however,  that  these  prolongations 
constitute  but  a  small  portion  of  the  bulk  of  the  white  substance.  New 
systems  of  fibres  enter  into  its  composition:  these  are  not  only  the  central 
expansions  of  the  nerves  of  sense,  which  on  their  entrance  into  the  brain 
substance  subdivide,  disperse  themselves  in  various  directions,  and, 
amongst  other  things,  appear  to  form  a  larger  membranous  expansion 
in  its  interior,  but  also  the  new  systems  of  fibres  furnished  by  the  com- 
missures, and  the  so-called  investing  membrane  (Belegungssuhstanz). 

It  would  be  of  great  importance  to  know  the  conditions  of  mixture 
and  of  disposition  of  each  of  these  systems  of  fibres,  and  their  relation  to 
the  corresponding  prolongations  of  the  three  columns  of  the  spinal  cord. 
Hitherto  the  efforts  made  to  elucidate  this  point  have  not  been  fully  suc- 
cessful, but  recently  an  advance  has  been  made  in  unravelling  the  different 
systems  of  fibres  of  the  white  substance  of  the  brain.  According  to  the 
present  state  of  our  knowledge,  the  following  principal  systems  are  found 
in  it. 

(1.)  The  system  of  fibres  of  the  corona  radiata  {Stahkranz).  These 
enter  into  all  the  convolutions  of  the  external  surface  of  the  hemispheres, 
especially  at  the  posterior  parts,  and  extend  even  to  the  summit  of  the 
convolutions.     A  preponderating  relation  to  the  motory  functions  may  be 


12  PRELIMINARY    ANATOMICAL    OBSERVATIONS. 

attributed  to  this  system  of  fibres.  The  corona  radiata  is  not  simply  the 
prolongation  of  parts  of  the  medulla  oblongata;  this  is  evident  from  the 
remarkable  size  which  it  presents  in  man  in  proportion  to  that  of  the  me- 
dulla oblongata.  In  most  of  the  lower  animals  the  reverse  is  the  case; 
the  corona  is  relatively  smaller  than  the  medulla. 

(2.)  The  expansion  of  the  corpus  callosum.  The  corpus  callosum 
(like  the  pons  Varolii  in  the  cerebellum)  ought  to  be  considered  as  the 
analogue,  more  highly  developed,  of  the  anterior  commissure  of  the 
spinal  marrow.  It  appears  to  be  formed  principally  by  the  fibres  of  the 
corona,  Avhich  in  passing  forward  cross  here,  and  pass  to  the  hemisphere 
of  the  opposite  side;  therefore  the  dependence  of  each  half  of  the  body 
upon  the  oppossite  hemisphere.  The  fibres  proceeding  from  the  corpus 
callosum  radiate  to  all  the  convolutions  of  the  hemispheres,  especially, 
however,  to  their  internal  and  superior  parts. 

(3.)  The  system  of  fibres  of  the  anterior  commissure;  of  which  a  part 
suddenly  terminates  in  the  inferior  convolutions  of  the  middle  lobe  of  the 
brain,  another  part  enters  into  the  posterior  lobe,  from  which  it  spreads 
over  the  whole  extent  of  the  superior  border  of  the  hemispheres.  The 
anterior  commissure  appears,  therefore,  to  be  in  man  an  apparatus  of 
connection  between  the  two  hemispheres  in  their  totality  (in  many  ani- 
mals rather  a  connection  between  the  olfactory  lobes).  The  high  psychi- 
cal function  which  by  some  has  been  attributed  to  this  system  appears  to 
me  to  be  in  the  highest  degree  doubtful;  the  very  considerable  size  which  it 
])resents  in  the  Kangaroo  (Gratiolet)  seems  rather  to  indicate  that  it  has 
.some  connection  with  the  movements  of  the  lower  extremities. 

(4.)  The  expansions  of  the  nerves  of  sense  within  the  brain,  and  in 
particular  of  the  optic  nerve.  A  fan-formed  expansion  can  be  distin- 
guished within  the  hemispheres  passing  from  the  optic  tract  to  the 
summit  of  the  posterior  lobe;  other  such  radiations  pass  forwards  in  all 
the  anterior  convolutions,  the  high  development  of  which  is  characteristic 
of  the  human  brain.  The  optic  nerve  and  its  roots  are  in  the  human 
species  relatively  small,  but  the  expansion  of  the  nerve  within  the  brain 
assumes  an  extraordinary  development.  This  expansion  is  not  to  be  con- 
sidered throughout  as  a  simi)le  continuation  of  the  fibres  of  the  nerves 
itself,  but  rather  as  the  result  of  a  multiplication  of  these,  or  of  the  addi- 
tion of  a  new  system  of  fibres  to  the  optic  nerve.  This  high  development 
of  the  expansion  of  the  optic  nerve  appears  to  constitute  an  essential 
characteristic  of  the  human  brain,  and  also  of  that  of  the  higher  apes, 
and  to  represent  an  apparatus  devoted  to  some  of  the  most  important 
mental  functions.  In  nearly  all  mammiferous  animals  the  impressions  of 
sight  appear  to  excite,  to  a  very  great  measure  in  the  corpora  quadrige- 
mina  to  which  the  comparatively  large,  in  many  animals  perhaps  only 
root,  of  the  optic  nerve  proceeds,  much  more  simple  and  more  im- 
mediate reflex  actions;  in  man,  on  the  contrary,  most  impressions  trans- 
mitted by  the  optic  nerve  appear  to  experience  in  that  expansion  within 
the  cerebrum  a  further  psychical  elaboration  (by  combination  with  fibres 
and  ganglion  masses  of  other  systems),  before  acting  upon  the  movements. 
There  appears  to  exist  within  the  cerebellum,  and  likewise  within  the 
cerebrum,  an  expansion  furnished  by  the  auditory  nerves;  it  appears  to 
enter,  with  the  continuation  of  the  fibres  of  the  posterior  column  of  the 
spinal  cord,  through  the  optic  tlialami  into  the  hemispheres. 

(5.)  Special  systems  of  fibres  which  pass  from  one  convolution  to 
another,  and  line  the  internal  aspect  of  the  cortical  substance.  To  these 
systems  the  fibres  of  the  gyrus  fornicatus  appear  to  belong,  which  radiate 


PKEL.IMINARY    ANATOMICAL    OBSERVATIONS.  13- 

in  all  the  convolutions  of  the  internal  aspect  of  the  hemisplieres;  the 
arciform  fibres  also  constitute  commissures  between  tlie  different  parts  of 
the  same  hemisphere.  While  in  the  gray  substance  conduction  and  com- 
munication of  impressions  to  all  parts  is  provided  for,  these  fibre  systems 
of  the  white  substance  appear  to  furnish  likewise  a  most  complete  means 
of  communication  between  all  parts  of  the  hemispheres. 

The  prolongations  of  the  posterior  columns  of  the  spinal  cord,  or,  at  all  events, 
the  bundles  of  fibres  in  direct  communication  with  them,  give  off  successive 
portions  to  the  cerebellum,  the  corpora  quadrigemina,  the  optic  tract,  and  the 
hemispheres.  According  to  Foville,  whose  researches  inoreover  require  confirma- 
tion in  many  points,  there  exist  within  the  cerebrum  two  large  groups  of  fibres, 
distinct  in  their  mode  of  disposition  but  interlaced  with  one  another,  one  of 
which  is  connected  to  the  anterior  and  lateral  columns,  the  other  to  the  posterior 
columns.  To  the  latter  group,  which  is  much  the  more  important,  belong  not 
only  the  successive  enlargements  which  are  fovmd  upon  the  axis  of  the  brain, 
the  corpora  quadrigemina,  the  optic  thalami  and  corpora  striata  with  their  gray 
kernels,  but  also  all  the  corpus  callosum,  the  septum  lucidum,  and  the  fornix 
with  its  dependencies,  which  all  surround,  in  a  circular  manner,  the  cone  of  fibres 
which  proceeds  from  the  anterior  and  lateral  cords,  penetrates  the  gray  masses 
of  the  thalamus  and  corpus  striatum,  as  a  flattened  trunk,  and  ramifies  in  the 
interior  of  the  great  hemispheres.  According  to  Foville,  the  nervous  membrane 
of  the  surface  of  the  ventricles,  and  (as  that  in  Amnion's  horn  is  prolonged  into 
the  white,  most  external  lamella  of  the  cortical  substance)  the  entire  surface  of 
the  brain  is  intimately  related  to  the  prolongations  of  the  posterior  cord,  so 
that  the  prolongations  and  dependencies  of  the  lateral  and  anterior  cords,  from 
their  entrance  into  the  thalamus  onwards,  remain  absolutely  hidden  in  the  interior 
of  the  portions  furnished  by  the  posterior  cords,  and  never  step  out  upon  the 
surface  itself.  A  relation  would  here  exist  similar  to  what  is  seen  in  the  distri- 
bution of  the  peripheral  nerves,  where  the  cutaneous  and  mucous  surfaces  are 
likewise  supplied  chieflv  by  nerves  of  the  posterior  columns,  while  the  nerves 
from  the  anterior  and  lateral  columns  are  distributed  principally  to  the  subad- 
jacent  muscular  layers. 

According  to  this  view  the  brain,  as  a  whole,  would  have  to  be  considered  as 
a  great  ganglionic  enlargement,  which,  like  the  spinal  ganglia,  belongs  primarily 
to  the  prolongations  of  the  posterior  cords,  but  in  which  the  prolongations  of  the 
anterior  and  lateral  cords  not  only  enter  most  intimately  into  the  composition  of 
the  ganglia,  but  even  originate  in  them  (the  gray  cortex).  From  this  point  of 
view  the  cerebrum  would  represent  then  an  enormous  ganglion  resulting  from 
the  blending  of  the  optic  and  olfactory  nerves;  the  cerebellum  would  represent  a 
similar  one  resulting  from  the  auditory  nerve  and  fifth  pair.  This  appellation 
ganglion  may  be  allowed  to  remain;  a  more  minute  definition  would  lead  to  the 
conclusion  that  both  brains  form  the  inner  expansions  of  a  central,  and  partly 
special,  nervous  system,  in  which  the  immediate  prolongation  of  the  columns  of 
the  spinal  cord  are  combined  most  intimately  with  new  masses  of  gray  substance, 
with  new  systems  of  white  fibres,  in  particular  the  central  expansions  of  the 
nerves  of  sense— a  circumstance  the  physiological  importance  of  which  is  shown 
by  the  very  great  and  important  part  which  the  central  function  of  the  senses 
plays  in  almost  all  our  psychical  acts. 

§  12.  The  cerebellum,  therefore,  contains  prolongations  of  the  three 
columns  of  the  spinal  cord  in  the  compact  mass  of  medullary  hiyers  which 
forms  the  kernel  of  the  cerebellum  and  its  immediate  envelopes,  and  this 
kernel  is,  according  to  Foville,  surrounded  by  a  membranous  expansion 
of  nerve  substance  which  lines  tlie  internal  surface  of  the  cortical  sub- 
stance, and  is  formed  by  prolongations  of  the  auditory  nerve  and  of  the 
fifth  pair.  Both  nerves  send,  besides,  prolongations  into  the  layers  of 
fibres  of  the  kernel,  which  are  lined  in  their  interior  by  the  gray  fringed 
membrane  of  the  olives  of  the  cerebellum. 

From  the  lateral  columns  of  the  spinal  cord  an  important  contingent  goes 
with  the  corpus  restiforme  into  the  cerebellum;  these  fibres  go  principally  to  its 
hemispheres,  few  if  any  of  them  go  to  the  middle  portion.     The  fibres  of  the 


14  PRELIMINARY    ANATOMICAL    OBSERVATIONS. 

pons  Varolii  also  go  to  the  lateral  parts.  The  white  substance  in  the  interior  of 
the  cerebellar  hemispheres,  which  immediately  surround  the  olives,  comes  prin- 
cipally from  the  processus  cerebelli  ad  corpora  quadrigemina,  the  only  point  of 
direct  communication  between  the  cerebrum  and  the  cerebellum.  The  fact  of 
the  entrance  of  a  root  of  the  auditory  nerve  with  the  corpus  restiforme  into 
the  kernel  of  the  cerebellum  is  confirmed  by  Gratiolet.  Guillot  ('  L' Experience,' 
II.,  1888,  p.  497)  has  published  a  case  of  Notencephalie  in  which  the  auditory 
nerve  and  the  fifth  pair  entered  into  the  vesicles  which  corresponded  to  the  cere- 
bellum, the  optic  and  olfactory  nerves  into  the  parts  which  represented  the 
cerebrum.  It  is  certain,  however,  that  the  perceptions  of  sound  do  not  take  place 
in  the  cerebellmn.  The  little  that  can  be  said  regarding  the  functions  of  this  part 
of  the  brain  is  reduced  to  this,  that  it  appears  to  have  more  to  do  with  the  move- 
ments of  the  vertebral  column  and  the  trunk  than  with  those  of  the  extremities; 
probably  also  it  presides  ver  the  movements  of  certain  portions  of  the  viscera 
(the  genital  organs).  For  all  this  many  relations  of  the  auditory  nerve  and  the 
fifth  pair  have  yet  to  be  discovered.  The  cerebellum  appears  to  have  very  little 
to  do  with  the  higher  mental  functions. 

The  corpora  quadrigemina  also  are  evidently  organs  of  very  little  im-  ■ 
portance  psychically.     In  man  and  in  the  higher  animals  they  are  alwaj^s    1 
smaller  in  proportion  as  the  hemispheres  are  larger.     They  have  an  evi-     " 
dent  relation,  and  are  indispensable,  to  the  sense  of  sight;  principally, 
however,  they  constitute  the  apparatus  of  the  reflex  action  exerted  by  the 
sense  of  sight  upon  great  combined  muscular  movements. 

In  the  cerebrum  prolongations  of  all  three  columns  of  the  spinal  cord 
are  likewise  grouped  together,  so  that  the  anterior  and  lateral  parts  radiate 
towards  the  exterior,  are  surrounded  by  the  fore-mentioned  ring-like 
structures,  and  at  last  penetrate  upwards  in  the  centre  of  the  convolu- 
tions, into  the  gray  cortical  substance  (there  originate?).  The  white 
masses  of  the  hemispheres  are  not  connected  with  the  mass  of  peripheral 
nerves,  or  with  the  columns  of  the  spinal  cord,  but  with  the  cortical  gray 
substance;  the  surface  of  which,  according  to  Baillarger,  has  an  area  of 
1700  square  centimetres,'  not  in  relation  to  outward  sensation  and  mus- 
cular movement,  but  to  the  intelligence. 

Of  these  three  accessory  structures  (cerebellum,  corpora  quadrigemina,  and 
great  hemispheres),  which  are  superadded  to  the  cerebral  kernel  to  the  spinal 
marrow  in  the  brain,  it  is  always  the  last  which  stands  in  the  most  immediate 
relation  to  the  mind.  Unfortunately  their  functions  are  of  such  a  nature  that 
they  (like  those  of  the  cerebellum)  escape,  to  a  very  great  extent,  being  experi- 
mented upon.  Their  very  extensive  motory  function  presides  rather  over  the 
movements  of  the  extremities,  especially  of  the  arms,  of  the  tongue,  and  the 
countenance,  than  over  the  movements  of  the  trunk;  the  hemispheres  are  the 
seat  of  all  consciousness,  of  all  deliberations,  and  from  them  seem  to  proceed  all 
these  extremely  complicated  acts  intermediating  between  the  sensorial  impres- 
sions and  the  abstract  psychical  phenomena,  and,  again,  between  these  last  and 
the  movements;  the  limits  to  which  special  psychical  life  may  extend,  and  at 
which  sensation  and  movement  cease,  are  almost  arbitrary.  Think  of  the  endless 
multiplicity  of  the  movements  of  the  tongue  in  speech,  of  the  elaborate  uses  of 
the  limbs,  especially  of  the  hands,  what  innumerable  intuitions  and  impulses  of 
movement  must  here  take  place,  in  the  central  organs,  with  a  rapidity  and  har- 
mony which  are  unequalled.  These  faculties  alone  must  necessitate  a  far  greater 
development  of  the  hemispheres  in  man  than  in  any  other  animal.  We  often 
observe  in  diseases,  in  localized  injury  of  the  hemispheres,  that  the  media  between 
the  word  thought  and  the  movement  of  the  tongue,  between  determination  and 
the  use  of  members,  are  suppressed;  here  a  great  deal  appears  as  paralysis  which 
is  certainly  due  to  no  direct  affection  of  the  motory  apparatus,  but  of  psychical 
function.  Think,  on  the  other  hand,  of  the  endless  multiplicity  of  phenomena 
which  we  can  neither  name  nor  demonstrate,  which  are  produced,  for  example, 
between  the  impressions  of  sight  and  the  absti-act  ideas;  these  phenomena  are 
also  produced  by  causes  which  lie  in  the  apparata  of  the  hemispheres.     This 


'  Average  of  three  brains,  '  Annal.  Med.  Psychol  ,'  1853,  v.,  p.  1. 


I 


PUBLIMINARY    ANATOMICAL    OBSEKVATIONS.  15 

transformation  of  the  perceptions  being  much  stronger,  more  varied,  and  more 
developed,  in  man  than  in  any  other  animal,  it  must  be  admitted  that  more  com- 
plicated arrangements  are  required. 

The  two  nerves  of  tlie  cerebrum,  the  optic  and  the  olfactory,  commu- 
nicate with  the  surface  of  the  ventricles,  and  are  connected  by  the  ex- 
pansions of  their  roots,  witli  almost  all  the  fundamental  parts  of  the 
brain. 

As  the  blind  termination  of  the  ventricles,  the  infundibulum,  pos- 
sesses at  its  inferior  part  a  particular  appendage,  of  whose  function  we 
are  ignorant,  the  pituitary  body,  so  there  exists  superiorly,  upon  the  deli- 
cate blind  expansion  of  the  ventricular  cavity  which  forms  the  inferior  sur- 
face of  the  corpora  quadrigemina,  an  analogous  appendage,  the  pineal  gland. 
The  analogy  is  still  more  striking  when  the  configuration  of  the  neigh- 
boring parts  is  considered;  in  the  one  case  we  have  the  mammillary 
bodies,  in  the  other  the  corpora  quadrigemina,  but  while  one  of  these,  the 
pituitary  body,  is  only  in  connection  with  the  gray  substance,  the  other, 
the  pineal  gland,  communicates  only  with  the  white  substance.  These 
structures  appear  to  have  no  connection  with  the  psychical  and  sensorial 
functions. 

§  13.  In  the  examination  of  the  brain  in  the  body  of  one  who  has  been 
mentally  diseased,  the  state  of  the  cerebral  coverings  should,  in  the  first  place, 
be  minutely  investigated.  In  the  skull,  one  should  not  only  notice  those 
deviations  of  form  which  admit  of  being  easily  estimated,  such  as  marked 
obliquity,  knotty  curvature,  convexities  and  concavities,  but  should  also 
give  the  measurements  of  its  various  diameters,  the  thickness  and  tex- 
ture of  the  cranial  bones,  and  the  degree  of  ossification  of  the  sutures; 
this  in  young  persons  being  somewhat  morbid.  It  is  necessary  to  observe 
whether  the  skull  presents  on  its  internal  surface  any  nodes,  or  sharp  osseous 
projections,  to  examine  the  foramina  which  give  passage  to  the  great  ves- 
sels, and  also  the  great  veins  and  arteries  themselves,  with  reference  to 
contraction,  dilatation,  or  degeneration.  The  degree  of  repletion  of 
the  sinuses,  and  the  condition  of  the  blood  they  contain,  ought  to  be 
mentioned.  In  estimating  the  amount  of  blood  contained  in  the  mem- 
branes and  in  the  brain  itself  it  is  necessary  always  to  bear  in  mind  the 
total  quantity  of  blood  in  the  body,  as  a  considerable  quantity  of  blood 
within  the  cranium  in  great  general  jDlethora  is  of  much  less  significance 
than  in  opposite  anaemic  conditions.  In  the  healthy  brain  the  pia  mater 
and  arachnoid  are  thin  and  translucent;  there  is,  it  is  true,  a  degree  of 
opacity  along  the  line  of  the  longitudinal  sinus,  and  great  veins  which  is 
of  no  signification  in  adults  or  old  persons;  in  youth,  however,  it  is  impor- 
tant, as  it  marks  the  previous  existence  of  prolonged  hypersemia.  The 
same  may  be  said  of  the  Pacchionian  bodies,  and  this  is  also  true  with 
regard  to  the  amount  of  serum  within  the  cranial  cavity,  it  being  also  more 
considerable  in  old  men.  When  the  brain  is  healthy,  and  freshly  taken 
from  the  skull,  the  membranes  are  easily  detached  from  the  surface  with- 
out bringing  with  them  portions  of  the  cerebral  substance,  except,  per- 
haps, small  and  separate  flakes.  The  contrary  is  the  case  when  the 
brain  is  diseased.  The  convolutions  should  lie  close  to  one  another,  and 
their  surface  should  be  smooth  and  uniform:  an  unequal  rough  pitted 
surface  is  characteristic  of  atrophy  of  some  of  the  convolutions,  Avhich 
is  likewise  of  less  significance  in  old  age.  In  a  healthy  brain  the  whole  of 
the  gray  substance  should  contrast  strongly  with  the  white  substance;  the 
inner  layer  of  the  cortical  gray  substance  ought  to  be  a  little  clearer 
than  the  more  external  layers.     The  white  substance  ought  to  be  firmer 


16        '  PRELIMINARY    ANATOMICAL    OBSERVATIONS. 

than  the  gray;  some  parts,  as  the  pons  Varolii  and  the  medulla  ohlongata,, 
are  of  firmer  consistence  than  the  mass  of  the  white  substance.  More- 
over, the  consisteuce  of  the  brain  ought  to  be  uniform  over  all,  and 
partial  indurations  and  softenings  are  of  greater  significance  than  the 
degree  of  consistence,  the  hardness  or  softness,  of  the  brain  as  a  whole.' 

1  The  weights  of  the  brain  have  not  the  great  value  whicli  was  formerly 
attached  to  them  :  the  more  important  points  upon  this  subject  will  be  considered 
in  the  Fourth  Book. 


PKELIMINARY    PHYSIO  PATHOLOGICAL    OBSKEVATIONS.  17 


CHAPTER  III. 

PRELIMINARY   PHYSIO-PATHOLOGICAL   OBSERVATIONS 
ON   MENTAL   PHENOMENA. 

§  14.  The  function  of  the  spinal  marrow  is  to  conduct  impressions 
to,  and  impulses  of  movement  from,  the  brain.  Besides,  and  this  is  its 
principal  function,  it  produces  the  more  simi)le  reflex  acts,  the  transfor- 
mation, still  })retty  direct,  of  sensations  into  movements.  It  is  the  gray 
substance  whicli  is  the  seat  of  the  mediatory  functions  between  this 
double  centripetal  and  centrifugal  current;  reflex  action  constitutes  one 
of  its  specific  functions.  But  the  gray  substance  also  conducts  from  and 
to  the  brain.  Towards  the  brain  it  conducts  certain  qualities  of  sensa- 
tion which  could  not  be  conducted  by  the  posterior  column,  which 
evidently  also  originate  in  the  gray  substance  itself,  and  constitute  a  sort 
of  "psychical  "modification  and  transformation  of  the  centripetal  impres- 
sions. Inversely,  the  impulses  of  movement  from  the  brain  do  not 
appear  as  yet  to  possess  all  the  qualities  necessary  to  isolated  muscular 
contractions.  It  appears  to  be  in  the  gray  substance  that  these  impulses 
are  first  elaborated  and  arranged  in  a  proper  manner. 

All  the  impressions  transmitted  through  the  spinal  cord,  and  those 
proceeding  from  the  nerves  of  special  sense,  sight,  hearing,  etc.,  are  col- 
lected in  the  brain.  There,  without  being  confounded  the  one  with  the 
other,  tliey  meet,  are  combined,  associated,  brought  into  the  most  mani- 
fold relations  and  combinations,  and  awaken  within  the  brain  other  new, 
but  purely  subjective,  internal  images.  All  these  images  leave  behind 
traces  or  remains,  of  which  the  combination  produces  again  certain  gene- 
ral results  (Abstractions),  and,  quite  involuntary,  in  the  moment  even  of 
their  production,  they  are  already  logically  elaborated,  collected,  and 
associated  in  judgments,  conclusions,  etc.  All  these  phenomena  are  evi- 
dently intimately  related  to  the  activity  of  the  sensorial  sphere  of  the 
brain.  But  the  brain  is  also  an  immense  reflex  apparatus,  in  which  all 
these  states  of  sensorial  excitation,  of  which  this  organ  is  almost  constantly 
the  seat,  are  transformed  into  impulses  of  movement.  Here  also,  to  a  cer- 
tain degree,  simple  immediate  reflex  actions  from  sensory  excitations  to 
muscular  contractions  take  place;  generally,  however,  they  are  of  a 
very  complex  nature,  as  starts  from  fright,  harmonious  movements,  and  the 
like.  Much  more  characteristic  of  the  brain,  however,  are  the  reflex  actions 
from  those  already  elaborated  results  of  very  many  sensorial  acts,  modified 
by  opposing  influences,  and  which  have  become  more  or  less  abstract. 
They  are  followed,  on  the  motory  side,  by  reflex  actions  which  do  not 
manifest  themselves  in  immediate  muscular  contractions,  but  tend  rather, 
only  to  the  excitations  and  to  the  most  general  ideas  or  consequent  mus- 
cular movements  of  the  greatest  complexity  and  variety  (actions). 

All  these  functions  ought  also,  by  analogy,  to  be  attributed  princi- 
pally to  the  gray  substance  of  the  brain,  and  in  particular  to  the  cortical 
gray  substance  of  the  hemispheres;  the  great  extent  of  whose  surface 
5? 


18  PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS. 

constitutes  one  of  the  chief  characteristics  of  the  human  brain,,  which  is 
very  often  found  altered  in  mental  disease,  and  has  been  long  declared  by 
many  to  be  the  seat  of  the  "intellect"  and  of  the  "will."  The  intellect 
is,  it  is  true,  a  result  of  many  and  very  complicated  acts,  to  which,  also,  the 
process  of  transmission  is  indispensable;  but  this  even,  and  indeed  in  the 
most  complicated  manner,  ought  also  to  be  attributed  to  the  gray  substance. 
Between  the  perceptions  and  the  ideas  which  they  originate  as  between 
volition  and  the  resulting  acts  there  are  many  intermediate  conditions; 
these  will  have  to  be  sought  for  principally  in  the  white  system  of  fibres, 
and  here,  as  has  been  already  remarked,  it  is  impossible  to  fix  the  limit 
where  what  is  specially  psychical  begins. 

The  walls  of  the  ventricles  appear,  moreover,  to  be  of  considerable  importance 
in  regard  to  mental  function;  this  appears  to  be  shown  by  observation,  where 
there  is  a  large  accumulation  (especially  if  rapid)  of  cerebro- spinal  fluid,  and 
where  its  constitution  is  altered  with  superficial  maceration  of  the  ventricular 
walls;  in  those  cases  there  is  always  deep  dementia,  a  state  of  stupor,  etc.: 
several  pathological  anatomical  observations  upon  the  insane  also  show  this.  If 
■we  can,  on  this  account,  limit  the  mental  processes  principally,  but  not  exclu- 
sively, to  the  cerebral  gray  substance,  it  appears  on  the  other  hand  very  probable 
that  all  the  free  surfaces  of  the  brain,  the  cortical  gray  substance,  as  well  as  the 
ventricular  walls,  are  especially  related  to  the  mental  processes;  that  their  healthy 
action  depends  upon  the  integrity  of  this  free  surface  of  the  brain  and  that  it  is 
principally  disturbances  in  it  which  give  rise  to  the  symptoms  of  insanity.  On 
the  other  hand,  where  disorganizations  occur  somewhat  deeper  in  the  cerebral 
substance,  disturbances  of  movement  are  seldom  absent;  and  they  generally 
accompany  the  mental  derangement  when  the  lesion  extends  from  the  surf  ace  of 
the  ventricle,  or  the  cortical  substance,  deeper  into  the  interior  of  the  brain. 
Limited  inflammations  in  the  white  substance  (without  pressure  on  the  brain) 
never  give  rise  to  great  disturbances  of  the  higher  mental  faculties;  occasionally 
they  cause  no  disturbance  at  all,  as  if  the  semi-oval  centre  had  no  function.  It 
appears  to  be  chiefly  a  medium  of  transmission,  but  transmission  may  take  place 
by  several  ways,  and  so  be  enabled  to  avoid  the  injured  part. 

§  15.  The  central  nervous  system,  which  expands  itself  in  the  hemi- 
spheres, is  double  and  symmetrical,  like  the  peripheral  nervous  system. 
We  do  not,  however,  think  double  with  our  two  hemispheres  any  more  than 
we  see  double  with  our  two  eyes.  In  explanation  of  the  unity  of  the 
thoughts,  as  well  as  of  the  impressions  of  sense,  we  must  look  to  the  mid- 
dle simple  parts  of  the  brain,  the  commissures.  It  is  certain,  however, 
that  injuries  and  disorganizations  affecting  both  halves  of  the  brain,  even 
when  they  are  relatively  unimportant,  give  rise  to  much  more  serious  and 
more  general  symptoms,  especially  of  a  psychical  kind,  than  diseases  lim- 
ited to  one  side.  Therefore,  when  anatomical  changes  are  found  in  the 
brain  in  mental  disease,  these  changes,  although  often  unimportant  in 
themselves,  almost  always  affect  both  sides,  and  a  wide  extent  of  struc- 
ture (Hyperaemias,  Atrophy,  etc.). 

'  Cases  have  been  recorded  in  which,  with  very  considerable  atrophy  of  one  of 
the  great  hemispheres,  the  mental  faculties  have  remained  intact.  One  hemi- 
sphere, therefore,  may  suffice  for  the  performance  of  the  mental  functions;  yet 
it  has  been  observed,  that  in  these  cases  the  mind  is  very  easily  fatigued.  It 
seems  that  in  such  circumstances  the  activity  developed  by  the  one  hemisphere 

^  can  go  on  only  for  a  short  time  with  a  certain  energy,  as  if  in  health  a  continual 
interchange  of  function  between  both,  or  a  distribution  of  the  mental  activity 
over  the  two  hemispheres,  took  place. 

The  opinions  of  Wigan  ('  Duality  of  Mind,'  London,  1844),  who  assumes  a 
complete  duality  of  the  mind  in  the  two  cerebral  hemispheres;  the  conjecture  of 
Holland  ('  On  the  Brain  as  a  double  organ,  Chapters  on  Mental  Physiology,'  2d 
Ed.,  London,  1858,  p.  179),  that  many  mental  disorders,  especially  the  states  of 
mental  disunity  and  internal  contradiction,  depend  upon  a  disharmony  m  the 
functions  of  both  hemispheres;  and  lastly,  the  recent  attempt  of  FoUet  to  refer 


PKELIMINAEV    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  19 

mental  aberrations  to  "  disturbance  in  the  equilibrium  of  the  innervation  of  the 
two  hemispheres,"  are  wanting  in  sufficient  proof. 

In  a  single  case  of  quite  recent  disease  melancholia,  with  ideas  of  persecution, 
attempts  at  suicitle  (a  brother  being  insane),  we  have  heard  the  patient,  who 
could  still  give  a  good  account  of  his  state,  say  that  he  felt  very  well;  that  he 
was  deranged  only  on  one  side,  the  right  side  of  the  head.  Analogous  cases  have 
been  published.  Friedreich,  '  Allgem.  Pathologic  der  psychischen  Krankheiten.' 
Erlangen.  1839,  p.  61;  and  Demme,'  Ueber  ungleiche  Grosse  beider  Gehirnhalf ten. ' 
Wurzburg,  1831,  p.  78.  We  are  not  disposed  to  attach  much  importance  to  these 
facts. 

§  16.  The  psychical  life  of  man,  as  of  other  animals,  commences  in 
the  organs  of  sense,  and  the  constant  current  as  which  we  perceive  it, 
passes  out  again  into  the  organs  of  movement.  The  transformation  of 
the  sensitive  excitation  to  the  motor  is  the  foundation  of  the  scheme  of 
reflex  action,  with  or  without  sensitive  perception.  In  the  lower  animals 
and  in  children,  simple  forms  of  this  psychical  taking  in  and  giving  out 
can  be  observed  in  different  degrees  of  development.  Here  we  see, 
little  modified  and  influenced  by  clear  and  energetic  perceptions,  changes 
of  the  sensitive  impressions  into  motory  excitation  in  the  impulses  to 
lively  movements  in  the  immediate  saying  and  acting  according  to  the 
momentary  impressions  of  sense.  Between  these  two  fundamental  acts  7 
of  the  psychical  life  something  else  is  interposed,  excited  by  the  sensa- 
tion, a  third  element,  which  presents,  it  is  true,  some  analogy  to  the  sen- 
sation, and  is  in  the  closest  connection  with  it,  but  is  not  really  it.  It  , 
forms,  as  it  were,  an  accessory  sphere  which  treads  midway  between  sen-  \J 
satiou  and  motory  impulse,  and,  as  it  gi'ows,  acquires  richness  and  extent; 
it  becomes  gradually  a  powerful,  and  in  itself  a  complex  centre  which 
rules  in  many  relations  sensation  and  movement,  and  within  which  moves 
the  whole  mental  life  of  the  man.  This  sphere  is  that  of  the  intelli- 
gence. 

All  mental  acts  take  place  within  the  intelligence.  This  is  the  special 
seat  of  thought,  and  all  the  various  mental  acts  Avhich  were  formerly 
designated  separated  faculties  (imagination,  will,  emotions,  etc.)  are  only 
different  relations  of  the  understanding  with  sensation  and  movement, 
or  the  result  of  the  conflicts  of  ideas  with  themselves. 

What  is,  properly  speaking,  intelligence,  what  occurs  within  the  brain 
when  one  thinks,  nobody  knows,  but  the  forms  of  its  procedure  are 
accessible  to  observation,  and  the  locality  where  it  performs  is  not  un- 
known. All  seems  to  indicate  that  it,  at  all  events  proper,  clear,  evident, 
thought,  is  referable  to  the  cerebrum.  And,  moreover,  it  may  with  rea- 
son be  said,  that  thought  is  an  act  most  closely  related  to,  and  is  even  to 
be  reckoned  amongst,  the  inner  sensorial  functions.  There  appears  to 
occur  in  perception  essentially,  on  the  one  side,  a  subjective  (generally 
very  weak,  languid)  excitation  of  the  sensory  centres,  and  on  the  other 
side,  a  combination  of  several,  and  many  of  these  excitations  into  a  gen- 
eral image  (Abstracts),  and  moreover,  one  can  put  to  flight  each  of  those 
impressions  from  which  the  whole  has  resulted. 

In  the  wider  sense  of  the  term  (in  the  sense  which,  for  example,  the  word  is 
used  by  Herbert)  every  intellectual  act,  active  or  passive,  and  naturally  also  sen- 
sation, is  a  perception.  Sensation  is  a  perception  which  has  arisen  in  the  brain 
through  immediate  transmission  of  an  excitation  that  has  acted  upon  a  centripetal 
fibre.  A  great  number  of  other  perceptions  are  not  immediately  provoked  by 
irritation  of  the  sensitive  nerves,  but  are  produced  internally  by  the  functions  of 
the  brain  which  are  independent  of  all  sensorial  excitation.  They  are  also  inti- 
mately dependent  upon  the  traces  which  former  sensorial  impressions  have  left 
in  the  brain,  and  with  the  inward  phenomena  of  the  sensation. 


20  PRELIMINARY    PHYSIO  PATHOLOGICAL    OBSERVATIONS. 

We  speak  of  the  "perceptions  "  sometimes  only  as  of  things  known,  that  is  to 
say,  which  are  actually  presented  to  the  mind  with  a  certain  degree  of  force  and 
clearness:  sometimes  also  we  speak  of  them  as  absent  (apparently  concerned  in 
the  memory,  but,  in  fact,  existing  rather  in  the  state  of  dispositions).  There  is 
in  intelligence  an  actual,  though  to  us  an  unconscious  life  and  movement;  we 
recognize  it,  however,  by  its  results,  which  often  suddenly  make  their  appearance 
from  some  unexpected  source.  A  constant  activity  reigns  over  this  almost,  if 
not  wholly,  darkened  sphere,  which  is  much  greater  and  more  characteristic  for 
the  individuality  than  the  relatively  small  number  of  impressions  which  pass  into 
the  state  of  consciousness.  A  number  of  physical  irritations,  of  impressions 
from  the  interior  of  the  organism,  strike  at  first,  and  even  so  to  speak  exclusively, 
this  sphere,  and,  quite  unconsciously  to  us,  act  upon  it,  and  modify  the  occur- 
rences which  take  place  within  it.  The  occurrences,  the  movements  which  are 
produced  within  this  sphere,  contribute  greatly  towards  the  regulation  of  the 
character;  the  direction  of  our  tastes,  the  guidance  of  our  sympathies  and  anti- 
pathies. 

Great  and  rapid  changes  in  the  ideas  are  occasionally  (though  very  rarely) 
accompanied  by  perceptible  occurrences  in  the  head,  by  a  feeling  as  if  something 
opened  or  shut  itself,  as  if  a  slight  jerk  were  received,  like  the  gathering  and 
scattering  of  clouds.  Guislain,  '  Legons  Orales,'  II.,  page  178,  and  Trelat,  '  Annal. 
Med.  Psychol  ,'  1856,  VIII.,  p.  175,  mention  such  cases;  and  a  case  is  also  known 
to  myself  in  which  I  am  certain  that  no  deception  took  place.  It  is  not,  of  course, 
to  be  thought  that,  in  these  cases,  changes  m  the  cerebral  processes  are  felt;  it 
appears  rather  to  be  events  which  take  place  in  the  membranes,  changes  in  the 
amount  of  blood  they  contain,  perhaps  in  the  distribution  of  the  cerebro-spihal 
fluid,  or  the  like. 

§  17.  We  have  been  led  to  consider  the  whole  brain  as  two  ganglia 
upon  the  nerves  of  sense,  in  which  the  central  expansions  of  these  unite 
with  new  nerve  substance.  In  accordance  with  this,  we  find,  in  the  ana- 
lysis of  the  intelligence,  that  the  constant,  simultaneous,  and  reciprocal 
action  of  the  mental  activity  with  the  central  sensorial  activity  is  of 
primary  importance.  Not  only  is  the  intelligence  constantly  awakened, 
excited)  and  entertained  by  the  sensorial  impressions,  not  only  does  the 
reverse  very  often  occur,  the  sensorial  function  being  laid  claim  to  and 
excited  by  the  intelligence  (hallucinations,  illusions,  delusions,  etc. ),  but  all 
our  perception,  if  it  be  only  somewhat  clear,  ought  constantly  to  be 
accompanied  by  some  degree  of  sensorial  activity,  by  feeble  and  vague 
sensorial  images.  The  plainest  and  clearest  perception  is  that  which 
occurs  with  the  aid  of  the  sense  of  sight,  in  which  visual  images  essen- 
tially enter,  whence  also  the  supposition  is  most  probable  that  it  belongs 
to  the  ganglion  of  the  optic  nerve,  to  the  brain  ;  in  the  intelligence  of 
animals,  where  the  olfactory  nerve  forms  very  extensive  expansions  upon 
the  ventricular  walls,  the  perceptions  of  smell  may  indeed  play  a  very 
important  part.  On  the  contrary,  the  ideas  resulting  from  pure  sensa- 
tions of  sound  (for  example,  the  musical  idea)  are  very  vague,  undecided, 
and  very  difficult  to  express;  and  it  is  very  remarkable  that  for  the  ex- 
pression of  this  idea — which  consists  simply  of  joint  impressions  from 
many  analogous  objects,  wherein  the  concrete  element  is  effaced,  and  for 
which,  therefore,  it  can  never  give  a  sufficient,  adequate  institution, 
especially  for  the  purpose  of  intelligible  perception— we  have  no  other 
means  at  our  disposal  than  again  sonorous  images,  namely  words. 

Speech  is  a  process  much  too  complicated  to  admit  of  its  being  referred  to  any 
particular  part  of  the  brain.  Some  parts  on  its  lower  portion,  the  surface  of  the 
fourth  ventricle,  the  olivary  bodies,  which  are  in  man  more  fully  developed  than 
in  any  other  animal,  may  indeed  be  closely  related  to  the  expression  of  the 
thoughts  and  to  articulation;  at  all  events,  however,  there  are  other  parts  of  the 
brain,  and  particularly  the  anterior  portion  of  the  hemispheres,  which  are  very 
important  in  speech. 

It  is  principally  in  pathological  cases,  where  the  words  fail  although  the  cor- 


PEELIMINAEY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  21 

t 

responding  thoughts  are  present,  or  where  continually  words  quite  different 
from  those  meant  are  pronounced,  that  •we  see  how  much  must  co-operate  in  the 
wonderful  mechanism  of  speech.  This  kind  of  affection  does  not  occur  most  fre- 
quently in  mental  disease,  it  occurs  chiefly  in  diseases  of  the  character  of  localized 
inflammations,  in  the  sensorial  centre,  or  more  particularly  in  the  hemispheres. 
We  shall  afterwards  refer  to  the  changes  which  occur  in  speech  in  mental  diseases. 
The  true  psychological  nature  of  words  is  very  frequently  not  properly  recog- 
nized. Words  are  conventional  images  of  sounds,  signs  for  already  very  y[ 
generalized  forms;  by  themselves  they  give  no  concrete  ideas,  but  only  the  exci- 
tation to  such,  to  a  number  of  ideas  only  to  a  small  extent  developed,  only  frag- 
mentarily  entering  into  the  state  of  consciousness,  and  tiae  details  of  which  vary 
in  each  individual.  Thus  it  is  that  different  individuals  attach  different  ideas  to 
words;  this  is  why  it  is  difficult  to  give  the  correct  and  exact  definition  of  the 
ideas  which  invoke  the  words,  and  to  determine  the  question,  which  is  to  be 
understood  by  the  words,  and  their  possible  combinations.  The  excitation, 
often  so  uncertain,  of  ideas  which  disappear  again  before  their  complete  develop- 
ment, and  are  replaced  with  new  ideas,  also  incompletely  developed,  incurs  the 
danger  of  superficiality  and  abstractness,  of  the  want  of  sensitive  concrete 
thought,  to  one  who  is  accustomed  to  keep  simply  to  words.  Without  doubt, 
all  the  higher  mental  functions  are  bound  in  an  intimate  manner  to  speech; 
animals  are  mute,  speech  is  a  property  peculiar  to  the  soul  of  man.  There  are, 
however,  moments  of  our  existence  when  our  inner  life  seems  for  once  to  be 
elevated  above  the  form  of  words,  when  things  unspeakable,  inexpressible, 
unheard  by  human  ear,  rise  as  from  a  suddenly  opened  depth,  and  upon  after 
reflection,  perhaps  it  seems  to  us  as  if  all  which  we  know,  or  may  yet  attain, 
could  never  be  a  realization  of  what  our  innermost  thoughts  had  conceived  in  a 
single  such  moment.  Then  one  comprehends  for  the  first  time  what  is  meant 
by  '  despising  the  word.'  Such  circumstances  which  by  their  nature  are  accom- 
panied by  very  strong,  even  overflowing,  feelings,  are  probably  more  frequent 
in  the  various  states  of  mental  disease  than  in  health. 

§  18.  A  closer  comparison  of  the  mental  processes  within  the  sphere 
of  the  intelligence,  with  those  depending  on  the  emotions,  reveals  to  us 
many  important  analogies,  and  also  some  differences,  which  are  worthy 
of  consideration  as  rendering  more  simple  the  study  of  insanity. 

1.  In  the  first  place,  it  ought  to  bo  remembered  that  there  exists  a 
similarity  in  the  general  conditions  of  irritation  and  irritability  in  per- 
ception and  in  sensation.  In  both  there  is  perfect  rest  only  in  the  deepest 
sleep;  ordinary  rest,  which  appears  for  example  in  the  sense  of  sight  as 
darkness,  in  the  understanding  as  vacancy,  is  still  function,  there  is  con- 
sciousness of  the  dark  field  of  vision,  of  the  void  in  the  sphere  of  percep- 
tion. But  the  proper  affection  of  the  subject,  that  which  in  the  sensation 
is  color,  sound,  smell,  etc.,  is  always  the  reality,  that  is,  the  perception 
of  which  we  are  conscious.  As  there  are,  in  seeing,  hearing,  etc.,  many 
degrees  of  strength  and  clearness,  so  also,*  in  this  knowledge  of  the  per- 
ception, there  are  varieties  of  strength  and  clearness. 

2.  For  the  development  and  normal  progress  of  the  perception,  as 
well  as  of  the  seiisation,  a  steady,  moderate,  and  adequate  excitation  from 
without  is  necessary.  In  the  functions  of  sense,  this  excitation  is  pro- 
duced by  actual  external  irritation,  and  that  which  happens  in  the 
sensitive  nervous  system  is,  in  the  so-called  eccentric  phenomena,  again 
referred,  transported,  projected,  to  the  place  of  the  accustomed  peripheral 
excitation.  The  perception,  on  the  other  hand,  never  receives  the  irrita- 
tions by  means  of  which  it  is  excited,  and  which  are  indispensable  to  its 
constant  function,  directly  from  the  outer  world,  but  always  through  the 
medium  of  sensation.  There  is  then  presented  in  the  perception  a  simi- 
lar eccentric  phenomenon,  a  projection  similar  to  what  takes  place  in 
sensation,  not  towards  the  peripheral  surface  or  the  outside  of  the  organ- 
ism— we  are  conscious  of  perception  rather  as  of  an  occurrence  within  our 
head — but  within  the  same  sphere  from  which  the  irritation  ordinarily 


22  PBELTMINAEY    PHYSlO-PATHOLOGlCAL    OBSERVATIONS. 

proceeds,  within  that  of  sensation.  This  eccentric  projection  of  percep- 
tions appears  to  be  that  wliich  necessitates  a  constant  entrance  of  sensitive 
images  into  them.  Through  it,  there  is  effected  in  the  central  organ  of 
sense  that  feeble  weak  hallucination  which  accompanies  all  perception, 
and  from  it  there  is  procured  that  sensitive  appreciation  of  color,  form, 
and  sound,  so  indispensable  to  its  clearness  and  vivacity,  and  wliich 
nature  has  meted  out  to  each  of  us  in  such  different  proportions.  _  It  is 
the  basis  of  all  the  psychical  phenomena  which  are  assigned  to  the  imagi- 
nation, and  especially  of  tliose  in  which  we  have  no  more  a  feeble  and 
vague  impression,  but  one  in  the  highest  degree  clear,  closely  resembling 
the  objective  perceptions  of  sense,  and,  like  them,  fully  awakened  by  the 
outward  activity  of  the  organs  of  sense — namely,  the  hallucinations  pro- 
per. Here  the  perceptions  act  in  such  a  manner  upon  the  central  sensory 
apparatus,  that  in  it  something  takes  place  which  ordinarily  is  produced 
only  upon  their  external  irritation;  namely,  an  act  of  sensation. 

3.  An  excess  of  irritation  has  in  both  spheres  the  same  consequences. 
An  intense  and  sudden  impression  of  light,  a  very  loud  sound  or  strong 
smell  (as  that  of  ammonia),  gives  a  powerful  and  violent  sensation, 
together  with  a  sudden  shock  of  the  sense.  Its  immediate  paralysis  may 
be  the  result.  This  has  been  frequently  observed  in  the  senses  of  sight 
and  hearing,  in  the  cutaneous  sensibility,  and,  in  a  rare  case  related  by 
Graves,  it  has  also  been  observed  in  the  sense  of  smell.  Should,  however, 
the  sense  not  be  quite  paralyzed  it  remains,  for  a  time  at  least,  less  sus- 
ceptible to  all  weaker  impressions,  and  the  incited  impression  continues 
for  a  long  time  after  the  cause  is  removed  (continued  apjiearance  of  the 
object  in  the  eye  after  one  has  been  blinded  by  looking  at  the  sun,  of  a 
report  of  a  cannon  in  the  ear,  etc.).  It  is  the  same  with  the  perception. 
In  man,  a  prodigious  mass  of  perceptions  of  a  certain  kind  are  suddenly 
incited  by  a  very  strong  impression,  and  here  also  the  shock  in  its  first 
strength  may  cause  even  paralysis  of  the  organ  (cases  of  sadden  death 
beginning  at  the  brain  from  violent  mental  influences);  but  if  not,  the 
complex  mass  of  perceptions  which  has  been  provoked  will,  at  all  events 
for  a  long  time,  have  the  sole  control  of  our  consciousness,  and  the  sus- 
ceptibility will  remain,  for  a  considerable  time,  notably  impaired  in  regard 
to  all  other  perceptions.  In  this  manner,  agitating  events  may  lay  waste 
and  impoverish  the  mind. 

§  19.  4.  Perception  and  sensorial  function  (and  here  again  the  rela- 
tions are  most  evident  in  the  sense  of  sight)  cannot  continue  for  an  un- 
limited time  in  quite  the  same  state;  they  appear  to  be  soon  fatigued  by  ar 
continuation  of  the  same  action,  and  therefore  a  certain  change  is  always 
necessary.  Where  no  motive  to  such  a  change  is  presented  from  without, 
a  new  sensation  or  perception,  purely  subjective,  will  be  called  forth  from 
the  original  perception.  The  simplest  phenomenon  of  this  nature,  with- 
in the  sphere  of  sensibility,  is  that  of  the  so-called  complementary  colors, 
and  subjective  contrast  colors  (the  appearance  of  blue  when  we  look  at 
an  orange  color,  of  violet  when  we  look  at  green,  etc.).  In  perception 
something  analogous  occurs,  in  it  this  process  proceeds  according  to  the 
fundamentally  obscure  relations  of  contrast  and  similarity.  When  a  per- 
ception has  lasted  for  a  certain  time  it  calls  up  anotlier,  similar  to,  or 
contrasting  with,  itself,  that  is  to  say,  there  may  be  produced  a  series  of 
perceptions,  either  altogether  new,  or  such  as  can  be  retraced  to  the  first 
perception,  which  continues  to  predominate. 

This  occurs  very  frequently,  for  example,  in  those  cases  where,  in  the  midst 
of  sad  ideas  excited  by  an  external  cause,  others  of  a  completely  opposite  nature 


PRELIMINARY    PHYSIO- PATHOLOGICAL    OBSERVATIONS.  23 

very  humorous,  suddenly  arise.  The  ideas  call  forth  each  other,  as  well  accord- 
ing to  the  sense  they  contain,  as  according  to  the  analogy  of  the  sensorial  images 
entering  into  them  (images  of  vision,  of  sound,  words);  the  last  is  sometimes 
seen  in  mental  disease,  especially  in  mania,  in  the  most  striking  manner,  where 
the  patient  finds  and  pronounces  with  great  rapidity  long  series  of  similarly 
sounding  words  which  are  unconnected  in  meaning,  or  at  least  connected  only 
by  the  niost  incoherent  sense. 

In  other  senses  than  that  of  sight,  especially  in  cutaneous  sensation,  and  par- 
ticularly in  pathological  conditions,  we  see  that  a  sensation,  for  example,  a  pain 
in  a  certain  part,  may  excite  an  analogous  sensation  (titillation,  pain,  etc.)  in 
another  part,  and  that  these  have  always  a  tendency  to  accompany  the  primary 
sensation. 

In  so  far  as  through  the  so-called  association  of  ideas  no  new  percep- 
tions are  originated,  but  only  some  are  awakened  and  reproduced  out  of 
the  store  of  perceptions  which  were  formerly  present,  this  process  is  called 
the  memory.  The  more  intimate  proceedings  of  this  process  of  repro- 
duction are  obscure,  and  quite  incomprehensible;  old  ideas  suddenly  arise 
without  any  origin  being  discoverable  in  the  ideas  that  have  been  present, 
even  as  those  reproductions  of  sensorial  images,  which  Henle  described 
under  the  title  of  the  memory  in  the  senses,  reappear  suddenly,  and  with- 
out motive,  in  the  field  of  vision. 

It  is  upon  this  central  reprodviction  of  the  perception  that  all  the  more 
delicate  mental  processes  of  combination  depend,  and  therefore  the  intelligence 
is  very  much  affected  by  anything  which,  to  any  extent,  impairs  the  memory. 
In  many  mental  diseases,  particularly  in  dementia,  the  impossibility  of  judging 
correctly,  and  of  forming  right  conclusions,  is  owing  to  the  destruction  of 
memory.  Ideas  are  more  easily  retained  and  reproduced  according  to  the  degree 
of  strength  and  of  force  with  which  they  at  first  entered,  and  to  the  healthiness 
and  activity  of  the  brain.  Any  disease  of  the  brain  may  impair  or  destroy  the 
memory;  consequently  the  state  of  the  memory,  in  many  of  the  insane,  indicates 
the  severity  of  their  malady.  Even  slight  changes  in  the  cerebral  states,  as,  for 
example,  the  eflEects  of  alcohol,  can  considerably  advance  or  retard  the  reproduc- 
tion of  ideas,  break  up  associations  of  ideas  which  were  formerly  familiar,  and 
recall  old  and  forgotten  combinations.  There  are  few  phases  of  mental  activity 
upon  which  the  effects  of  direct  physical  influences  are  so  evident  as  upon  the 
memory.  Nevertheless,  one  must  not  take  too  material  a.  view  of  the  matter. 
The  examples  of  quite  partial  loss  of  memory,  so  frequently  the  result  of  wounds 
or  diseases  of  the  brain,  in  which  one  might  infer  the  loss  of  the  apparatus 
devoted  to  a  particular  class  of  ideas,  appear  in  reality  to  be  more  general  in  their 
effects  than  might  at  first  be  supposed.  Here  there  appears  to  exist  a  general, 
though  moderate,  diminution  of  the  reproductive  power  whereby  those  which 
are  least  connected  with  the  individuality  are  the  ideas  most  liable  to  be  for- 
gotten.    (Gratiolet.) 

In  all  the  functions  of  the  central  organs,  even  of  the  spinal  cord,  there  is 
memory,  as  well  in  reflex  actions  as  in  sensorial  images,  words,  and  ideas.  To 
habit,  in  this  reproduction  of  acts  and  ideas,  which  becomes  always  more  facile 
and  mechanical,  stands  opposed  inspiration,  in  which  series  of  new  ideas  are 
produced. 

§  20.  5.  In  the  next  place,  the  circumstance  is  conclusive  that  in 
the  organ  of  perception,  as  in  that  of  sensation,  the  energy  special  to 
them  can  be  put  in  i)lay  not  only  by  their  normal  external  irritants,  but 
also  by  internal  irritation,  which  differs  from  perception  and  sensation 
itself;  in  particular  it  is  excited  by  morbid  irritation.  Inflammation  of 
the  choroid  is  followed  by  irritation  of  the  retina,  which  is  shown  by  the 
apparition  of  subjective  sensations  of  light,  of  various  colored  luminous 
globes,  flashes  of  light,  etc.;  likewise  all  irritation  applied  to  a  sensi- 
tive nerve  or  to  its  centre  can  call  forth  subjective  sensations  of  sound, 
smell,  taste,  cold,  burning,  formication,  etc.  In  the  same  manner  irri- 
tation of  the  brain,  through  internal  organic  irritation,  manifests  itself 


24:  PRELIMINARY    PHYSIO -PATHOLOGICAL    OBSERVATIONS. 

in  new  morbid  phenomena  of  perception.  As  inflammation  of  the  vascu- 
lar membrane  of  the  eye  causes  abnormal  sensations  of  light,  so  disease  of 
the  vascular  membrane  of  the  brain,  of  the  pia  mater  which  so  completely 
invests  its  free  surface  and  even  penetrates  into  it,  hypersemias  and  exu- 
dation on  this  membrane,  beget  also  anomalies  of  perception  (delirium), 
new  states  of  the  mind  proceeding  outwards  from  within  (agitations, 
emotions,  etc.),  which,  naturally,  occurs  to  a  still  higher  degree  in 
diseases  of  the  brain-substance  itself.  Besides,  it  is  not  only  these  serious 
and  palpable  diseases  which  cause  such  anomalies  of  perception.  It  is 
evident  that  the  cerebral  irritation  may  also  originate  through  the  com- 
munication of  nerve-state  from  distant  internal  organs,  as  the  heart,  the 
intestines, the  genital  organs.  That  the  nerves  of  the  abdominal  viscera 
are  intimately  related  to  the  cerebrum  and  cerebellum  has  been  experi- 
mentally proved;  and  as,  even  Avithin  the  physiological  limits  of  health,  the 
states  of  the  abdominal  viscera  have  an  evident  influence  upon  the  frame 
of  mind  as  a  whole,  and  upon  the  entrance  of  certain  kinds  of  ideas,  so 
morbid  irritation  of  the  nerves  which  have  their  source  in  these  organs 
will  frequently  induce  morbid  states  of  the  mind  wliich  sometimes  again 
disappear  upon  removal  of  the  peripheral  irritation,  although,  at  other 
times,  when  once  originated,  they  preseiwe  an  independent  and  perma- 
nent existence. 

It  may  be  here  mentioned  that  in  health,  as  in  disease,  such  organic  irrita- 
tions do  not  usually  excite  at  the  commencement  new  ideas  clear  and  definite, 
but,  in  tlie  first  place,  they  cause  those  vague,  indeterminate  modifications  of 
the  intelligence  which  are  designated  emotions.  In  particular,  the  rapidity  in 
the  succession  of  the  ideas,  and  the  manner  in  which  they  intermingle  are  mod- 
ified by  these  impressions  from  the  orgahism,  which  identifies  itself  with  the 
changes  of  the  feelings  and  tlioughts  '  something  like  the  flywheel  which  pro- 
longs the  received  movement,  sometimes  like  an  inert  burden  which  impedes  it 
or  renders  it  impossible.'  Lotze  has  very  correctly  pointed  out  this  relation 
which  exists  between  the  organs  and  the  thoughts.  "The  ulterior  development 
of  the  organism,"  says  he,  "acts  upon  the  soul  much  less  by  the  formation  of 
definite  ideas  than  by  causing  certain  fixed  natural  inclinations  or  certain  pecu- 
liarities of  the  movement  of  the  thoughts,  which,  as  inexpressible  first  proposi- 
tions, form  the  basis  of  the  views  and  conclusions  of  life.  The  sensations  from 
the  organs  of  the  body,  individually  feeble  and  vague,  in  their  sum,  however, 
powerful  and  effective,  act  upon  the  soul;  and  this  direction  of  the  mind,  in 
itself  aimless,  can,  however,  be  the  cause  which  guides  the  remaining  powers  of 
the  spirit  over  a  circle  of  adequate  and  determined  ideas."  Out  of  these  frames 
of  mmd,  particular  determinate  ideas  may  even  be  developed  when  aided  by  cer- 
tain circumstances. 

We  shall  find  the  same  in  insanity;  we  will  see  that  nearly  the  whole 
patliology  of  mental  disease  consists  in  mental  perversions  originating  from 
internal  organic  causes;  and  these  perversions,  in  turn,  give  rise  to  insane  ideas 
conformable  to  the  new  mental  disposition,  and  over  which  the  most  various 
circumstances  exert  an  influence. 

§  21.  6.  Perception,  like  sensation,  can  be  accompanied  by  pain  or 
pleasure;  in  this  respect  they  present  a  very  great  analogy,  which  is  all 
the  nnn-e  worthy  of  remark  as  mental  pain  is  a  fundamental  element  in 
insanity. 

In  sensation,  as  well  as  in  2>erception,  the  nature  of  pain  and  pleasure  is 
a  kind  of  vague  obscure  opinion,  on  the  one  hand  concerning  the  elevation, 
on  the  other  concerning  the  limitation  and  degradation,  of  the  /.  This 
opinion  can  be  connected  with  a  single  sensation  or  perception,  which 
will  then  be  felt  as  painful:  there  are,  however,  also  in  sensation,  as  in 
perception,  many  more  general,  more  vague  states  of  discomfort  where 
that  obscuro  opinion  is  not  related  to  any  single  sensation  or  perception, 


PBELIMINAKY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  25 

but  rather  to  sensation  or  perception  as  a  whole.  To  these  belong  the  states 
of  general  uneasiness,  of  bodily  ifialaise  without  localized  pain,  and  in 
perception,  the  feeling  of  oppression,  of  lowness  of  spirits  without  ade- 
quate cause,  which  moreover,  when  long  continued,  develop  in  turn  par- 
ticular, really  painful,  ideas. 

Mental  pain  may  be  occasioned  by  all  that  disturbs  the  normal  course 
and  combination  of  the  ideas  which  represent  the  /  (§  28),  and  which 
therefore  limit  its  freedom.  An  excess  of  mental  excitation,  which  awakes 
a  disordered  pressure  of  new  ideas,  as  also  a  deficiency  of  excitation 
(ennui,  indifference),  can  awaken  disagreeable  feelings;  so,  in  the  nerves 
of  sense,  pain  can  originate  as  well  through  violent  irritations  and 
tumultuous  impressions  as  from  the  abstraction  of  the  customary  excitant 
(cold,  hunger). 

It  has  been  shown  in  a  very  interesting  manner  through  the  effects  of  the 
inhalation  of  chloroform,  that  the  transmission  of  the  tactile  sensibility  can  be 
maintained,  while  the  sensation  of  pain  is  annulled;  and  Schiff  (Physiologie,  i.) 
has  recently  shown  that  in  the  spinal  cord  the  white  posterior  columns  possess 
the  property  of  conducting  tactile  impressions,  and  that  pain  can  be  transmitted 
only  by  the  gray  substance.  Evidently,  therefore,  pain  originates  in  the  gray 
substance.  It  is  by  no  means  improbable  that  also  in  the  organs  of  the  i^er- 
ception  the  phenomena  of  transmission  are  not  connected  immediately  and 
necessarily  ■with  the  phenomena  which  produce  mental  pain,  and  that  the  latter 
can  originate  directly  through  the  special  irritation  of  certain  constituent  parts 
of  the  cerebral  tissue. 

It  would  depend  very  much  upon  the  nature  of  the  individual, 
whether  the  derangement  of  the  normal  course  of  the  ideas  would  be  so 
felt  as  to  originate  mental  pain.  ^  delicate  versatile  mental  organization 
can  feel  great  annoyance  at  a  circumstance  which  would  not  at  all  disturb 
a  more  sluggish  intellect;  one,  for  example,  which  could  not  comprehend 
the  reasons  of  a  fact  nor  solve  a  problem.  Very  much,  however,  will 
depend  upon  the  state  of  irritation  in  which  the  organs  of  perception  are 
at  the  moment,  whether  or  not  the  idea  will  be  accompanied  by  pain. 
The  same  circumstance  can  produce  at  different  times  very  different  im- 
pressions; for  example,  if  it  happens  after  one  has  partaken  of  wine,  on 
return  from  the  opera,  or,  if  shortly  before,  something  disagreeable  has 
taken  place.  As  a  nerve  which  is  in  a  state  of  neuralgic  irritation  does 
not  react  upon  external  contact  as  in  the  normal  state,  and  pain  is  awak- 
ened by  the  slightest  impression,  so  there  are  states  of  the  brain  in  which 
every  mental  irritation  awakes  a  mental  pain  and  where  all  thought  is 
painful.  But  the  actual  state  of  irritation  of  the  brain  is  a  product  of  all 
the  former  states  of  irritation  in  connection  witli  the  irritation  now  act- 
ing. Where  frequent  and  profound  states  of  mental  ])uin  have  been 
experienced,  whether  on  account  of  an  original  predisposition  to  such,  or 
mental  impressions  of  an  adverse  kind,  there  is  gradually  formed  a  gene- 
ral painful  state  of  the  feelings  which  is  sometimes  persisteiit  and  some- 
times transient;  to  the  unfortunate  all  seems  sorrowful,  and  he  who  experi- 
ences many  reverses  falls  easily  into  a  state  of  permanent  sadness  and 
misanthropy.  We  shall  see  that  very  frequently  insanity  begins  with 
conditions  such  as  occasion  the  patient  to  receive  from  everything  pain- 
ful impressions,  and  that  this  frame  of  mind  is  in  many  instances  the 
result  of  disagreeable  events.  There  is  here  revealed  to  us  an  important 
mental  predisposing  cause  of  insanity  in  that  susceptibility  to  impression, 
that  tendency  to  easy  and  rapid  changes  of  mind,  in  which,  through 
every  mental  impression,  those  obscure  opinions  concerning  special  men- 
tal acts  are  awakened,  and  in  which,  by  degrees,  almost  every  idea  is 


26  PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS. 

converted  into  a  mental  disposition  wlierein  the  objective  impressions  are 
considerably  wealcened,  and  a  hypochondriacal  subjectiveness  and  egotism 
is  easily  indnced. 

Then  mental,  like  physical  pain,  has  this  peculiarity,  that  it  always 
presses  prominently  into  the  foreground  of  the  consciousness  and  permits 
little  else  to  enter  it;  indeed,  as  the  highest  degrees  of  physical  pain 
cause  external  anaesthesia,  its  highest  modes  are  accompanied  by  complete 
mental  insusceptibility  to  the  normal  excitants.  The  pupil  of  the 
mental  eye  contracts,  and  the  sharp,  fixed,  mental  pain  is  the  only  object 
with  which  it  is  occupied,  and  of  which  we  are  conscious;  as  in  hyperaes- 
thesia  of  the  sense  of  sight,  the  eye  withdraws  itself  from  the  excitation 
of  light,  at  other  times  agreeable,  and  seeks  the  darkness,  so  the  patient 
who  is  afflicted  with  mental  pain  avoids  mental  intercourse  with  the 
external  world  because  all  contact  is  painful  to  him,  and  abjectly  indiffer- 
ent to  all  around  him,  he  becomes  more  and  more  concentrated  in  him- 
self. Mental  pain  has  still  other  important  consequences.  On  account 
even  of  this  concentration,  all  other  perception  becomes  dull  and  slug- 
gish; ingenious  in  his  own  torment  and  constantly  occupied  with  his  pain, 
the  patient  becomes  unconscious  of  the  things  that  used  formerly  to  inter- 
est him;  they  are  momentarily  forgotten,  and  when  recalled  to  memory, 
the  impossibility  of  now  taking  his  accustomed  part  in  them  becomes  to 
him  a  new  source  of  grief.  As  every  mental  impression  is  disagreeable, 
there  is  developed  a  general  disposition  of  indifference  and  digust,  and 
benevolence  and  love  give  place  to  the  dark  impulses  of  suspicion  and 
hatred.  Again,  the  law  of  causality,  which  is  innate  in  the  human  soul, 
urges  him  to  search  for  the  causes — which  originate  only  from  Avithin — 
of  the  mental  pain:  these  are  sought  for  in  the  external  world,  because 
man  is  accustomed  to  receive  thence  the  incitements  to  his  mental  states: 
as  these  causes,  however,  do  not  really  exist  in  the  external  world,  there- 
fore the  ideas,  opinions,  and  conclusions  Avliich  the  patient  forms  are  false 
— they  are  delirious.  This  searching  for  causes  of  the  mental  perversion, 
these  attempts  at  explanation,  Ave  shall  afterwards  recognize  as  the  princi- 
pal source  of  the  delirium  of  insanity,  and  we  shall  see  that  in  this 
searching  after  causes  there  is  presented  to  the  mind  of  the  patient  not 
only  ideas  in  the  narrow  sense  of  the  word,  but  also,  through  the  influ- 
ence of  the  imagination  and  of  the  central  excitation  of  the  sensorial  ac- 
tivity through  the  perception,  many  various  hallucinations  and  illusions 
by  which  he  attempts  to  explain  his  state. 

Sensitive  pain  always  impairs  the  tonicity  and  movement  of  the 
muscles.  Sometimes  the  patient  carefully  avoids  all  movement,  and  in- 
stinctively rests  the  afEected  part ;  sometimes  the  movement  is  really 
rendered  difficult,  there  is  partial  paralysis  ;  or  sometimes  there  are  mor- 
bid movements,  contractions,  and  convulsive  tremblings.  The  mental  life- 
has  also  its  motory  side  (see  next  §),  and  this  is  affected  by  mental  pain 
in  a  similar  manner.  Sometimes  volition  is  chiefly  impaired  and  para- 
lyzed, the  patient  is  purposeless  and  inactive,  in  the  same  manner  as 
sensitive  pain  is  so  frequently  accompanied  by  a  state  of  profound  enfee- 
blement  of  the  central  organs  :  sometimes,  on  the  contrary,  it  adheres 
tenaciously  to  a  single  object — a  condition  Avhicli  may  be  interruiited  by 
rapid,  although  not  energetic,  mental  movement ;  sometimes  the  pain 
excites  outbreaks  of  violent  and  aimless  (convulsive)  effort,  such  as  is  not 
proportionate  to  its  duration.  As,  however,  in  the  so-called  muscular 
sensibility,  the  central  organ  is  conscious  of  the  condition  of  the  motory 
nervous  system,  so  also  we  are  conscious  of  these  states  of  the  motory  side 


PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  2T 

of  the  mental  life;  this  morbid  mental  languor,  this  absence  of  will,  this 
one-sided  adherence,  and  this  convulsive  jerking  of  the  efforts  are  again 
perceived  by  the  patient  as  a  kind  of  motory  2)ain,  Avhich  increases  still 
further  his  present  painful  condition. 

TJie  states  of  mental  pain,  anxiety,  fright,  sorrow,  grief,  etc.,  whether  brought 
about  by  internal  or  external  causes,  have  the  same  effects  upon  the  rest  of  the 
organism  as  physical  pain.  Sleep  disappears;  nutrition  is  impaired;  emaciation 
and  general  exhaustion  result.  Mental  pain  alternates  sometimes  with  neuralgias, 
accompanied  by  so-called  spinal  irritation;  at  other  times  it  originates  these  neu- 
ralgias; in  particular,  the  existence  of  that  epigastric  pain  (muscular  pain)  so 
frequent  in  spmal  irritation  is  often  observed.  At  other  times  it  is  complicated 
with  pliysical  anesthesia  of  various  degrees  (diminished  sensibility  to  tempera- 
ture and  to  bodily  pain,  excited  by  an  external  cause). 

The  states  of  mental  pleasure  give  entirely  opposite  results;  the  thoughtful 
reader  may  be  allowed  to  pursue  for  himself  their  analogies  with  the  nature  and 
the  results  of  the  agreeable  physical  sensations  (see  also  the  chapter  on  Mono- 
mania in  Book  III.,  and  various  articles  by  the  author  in  'Med.  Vierteljahrs- 
schrift,'  1843  and  1844). 

§  22.  As  the  special  function  of  the  brain,  perception,  is  most  inti- 
mately related  to  sensorial  activity,  so  also  there  exists  between  the  acts 
of  the  motory  nervous  system,  which  has  its  origin  in  the  same  organ, . 
and  the  perception,  a  very  direct  connection.     This  relation  is  very  ana- 
logous to  that  which  exists  between  perception  and  sensation. 

As  we  have  seen  that  the  sensorial  perceptions  leave  after  them  feeble 
and  faded  vestiges,  Aviiich  become  a  constituent  part  of  our  ideas  (§  18), 
it  is  the  same  with  the  impulses  of  movement ;  they  leave  behind,  in  the 
muscular  activity,  faded  designs  which  mix  with  our  ideas  as  perceptions 
of  movement.  There  is  an  intermediate  sphere  between  the  pure  percej)- 
tion  and  the  nervous  excitation  which  gives  rise  to  immediate  muscular 
contraction — a  s^ihere  for  which  there  exists  no  characteristic  expression, 
which  however,  contains  the  impulses  to  the  series  of  single  muscular 
movements  already  co-ordinated  in  great  groups  and  formed  beforehand  in 
our  mind.  Here  the  appropriate  impulses  of  movement  are  transmitted  to 
many  muscles,  which,  in  relation  to  single  muscles,  constitute  compre- 
hensive wholes,  but  which,  in  relation  to  our  special  actions,  only  again 
represent  fragments,  and  are  combined  ])artly  according  to  a  pre-estab- 
lished harmony,  partly  according  to  the  order  given  by  practice  and  custom. 
This  very  complicated  mechanism,  whose  seat,  according  to  physiological 
experiment  and  the  facts  presented  by  pathological  anatomy,  is  to  be 
sought  in  the  various  points  of  passage  of  the  continuations  of  the  ante- 
rior columns  and  the  pyramidal  columns  of  the  spinal  cord,  through  tlie 
gray  substance,  first  in  the  pons  Varolii,  then  in  the  cerebellum  and  in 
the  brain,  is  set  in  motion,  on  the  one  hand,  by  the  mass  of  sensorial 
irritation  which  meets  it  at  all  these  points.  It  presides  then  over  those 
instinctive  movements  and  actions  which  are  quite  independent  of  the 
intelligence,  or  which  depend  on  it  only  in  different  degrees,  and  thereby 
come  under  its  furthering  or  restraining  influence.  On  the  other  hand, 
however,  the  general  forms  of  these  great  impulses  of  movement  and 
their  ideal  reproductions  so  mix  themselves  with  our  mental  processes, 
that  they  enter  into  the  single  perception  as  essential  constituents. 
Thereby,  however,  the  idea  itself  assumes  a  motory  direction  tending  to 
muscular  movement,  and  thus  becomes  effort. 

The  mind  never  excites  our  voluntary  movements  in  the  sense  of  invoking 
single  muscles  to  contraction;  it  is  unconscious  of  these  muscles,  knowing  only 
the  internal  images  impressed  by  previous  sets  of  movements,  which,  when  once 


28  PKELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS. 

they  have  become  free  impulses  of  movement,  set  the  muscles  in  motion,  with- 
out further  mental  effort,  in  great  and  regularly  co-ordinated  groups  (walking, 
writing,  etc.).  In  the  more  limited  localized  brain  diseases,  those  of  the  pons 
Varolii,  the  cerebellum,  tlie  optic  thalami,  the  corpora  striata,  etc.,  we  see  usually 
derangements  of  this  mechanism,  suspension  of  its  connection  with  the  percep- 
tion, where  complicated  movements,  excited  by  the  irritation  of  the  disease,  are 
sometimes  involuntarily  performed  (walking  forwards,  moving  round  and 
round);  sometimes,  owing  to  the  mechanical  separation  of  the  brain  substance, 
the  influence  of  the  perceptions  can  no  longer  reach  this  mechanism  (for  exam- 
ple, paralysis  of  one-half  of  the  body,  owing  to  the  extravasation  into  the  corpora 
striata).  Sometimes,  also,  complications  of  these  two  causes  occur,  and,  indeed, 
within  quite  limited  spheres  of  movement;  e.  g.,  that  of  the  organ  of  speech,  so 
that  the  patient  cannot  pronounce  the  words  which  he  thinks,  or,  on  the  con- 
trary, expresses  words  which  he  has  not  thought. 

§  23.  The  mixing  of  tlie  intuitions  of  movement  with  our  perception 
is  the  intermediate  process  tlirough  wliich  every  manifestation  of  our 
intellectual  life  must  pass.  But  tliat  there  dwells  in  the  psychical  life 
within  us  an  overruling  tendency  to  express  itself,  to  exhibit  itself  in 
motions  and  acts,  depends  upon  tliis  general  fundamental  fact  which 
meets  us  everywhere  in  the  nervous  system — namely,  that  peripheral 
excitations  transform  themselves  in  the  central  organs  into  motory  im- 
pulses. At  different  stages  of  the  psychical  life  we  observe  that  different 
consequences  result  from  this  arrangement.  In  the  spinal  cord,  centripe- 
tal impressions  not  yet  received  into  consciousness  excite  irregular,  or  only 
partially  regular,  movements  of  muscles,  separate  or  in  groups  (the  most 
simple  reflex  actions).  All  the  organs  of  sense  are  accompanied  by  mus- 
cular apparatus,  which,  when  excited  by  the  state  of  the  nerve  of  sense, 
become  the  seat  of  involuntary  but  suitable  reflex  actions  which  accom- 
pany and  aid  the  sensitive  perception.  Also,  that  greater  mechanism 
which  contains  within  itself  the  impulses  of  movement  to  entire  series  of 
muscular  contractions  suitably  combined,  and  to  which  the  movements 
of  the  Avholo  body  are  ultimately  related,  is  set  in  action  by  the  sensorial 
impressions  according  to  the  simple  plan  of  reflex  action  ;  sometimes  it 
acts  harmoniously,  at  others  irregularly,  as  when  it  is  the  result  of  a  violent 
sensorial  impression.  Movements  of  the  former  kind  are  in  part  evoked 
by  sensitive  impressions  from  without,  as  may  be  observed  in  the  rhyth- 
mical movements  of  the  body  resulting  from  musical  impressions,  or  in 
the  rapid  so-called  instinctive  acts  consequent  on  strong  sensorial  impres- 
sions (turning  aside,  etc.).  Sometimes,  however,  the  causes  of  the  sen- 
sorial impressions,  which  occasion  the  action,  exist  within  the  body.  The 
impressions  from  the  whole  organism,  especially,  however,  from  the 
viscera,  the  intestines,  tlie  genital  organs,  etc.,  under  the  form  of  sen- 
suous requirements,  give  the  impulse  to  action  sometimes  moderate, 
sometimes  impetuous  ;  in  animals  they  rule  uncontrolled,  they  constitute 
the  principal  element  of  their  psychical  existence,  they  impel  them  to 
long  journeys,  and  govern  all  their  great  series  of  movements.  In  man, 
the  immediate  transition  of  these  sensations  to  movement  is  subject  in  a 
higher  degree  to  the  influence  of  the  understanding,  and  through  it  duty 
and  morality  intervene  to  control  and  govern  the  sensuous  desires.  But 
there  are  cases  where  these  lose  their  power.  In  the  insane,  in  whom  the 
influence  of  the  understanding  over  the  instincts  is  enfeebled,  and  more- 
over the  sensu  ous  impulses  perhaps  strengthened,  we  often  see,  for  example, 
the  appetite  for  food  or  the  sexual  instinct  showing  itself  with  the  most 
open  regardlessness.  Many  sad  examples  (of  shipwreck,  etc.)  have  shown 
that  hunger,  carried  to  the  highest  degree,  defiantly  overleaps  the  barriers 
"which  ethical  and  aesthetical  exhortatign  op])Ose  to  it;  and  also,  without 


PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  2& 

recurring  to  such  extreme  cases,  it  is  a  true  maxim  that,  even  amongst 
men  of  civilized  life,  hunger  and  love  are  the  strongest  motives  which 
direct  their  actions. 

In  animals,  the  immediate  reflex  actions  of  the  spinal  cord  in  the  brain  are 
much  stronger  than  in  man.  All  their  perceptions  have  the  tendency  to  be 
immediately  transformed  to  movements;  pure  calm  perception  seems  unknown 
to  them;  their  whole  psychical  life  is  connected  with  effort  towards  external 
objects.  In  man,  the  more  tliis  impulse  to  movement  is  governed  by  thought, 
the  more  the  mind  is  capable  of  pure  reflection,  the  less  this  impulsion  transforms 
itself  immediately  in  movement,  the  stronger  and  more  developed  seems  to  be 
his  intellectual  life. 

The  impulse,  the  necessity  to  muscular  movement,  to  action,  in  consequence 
of  such  sensitive  impulsions  as  proceed  from  the  organism,  is  called  (sensuous) 
instinct.  The  simplest  and  the  most  easily  understood  are  the  nutrient  and 
the  sexual  instincts  ;  the  special  instincts  which  belong  to  many  animals 
are  quite  obscure,  and  their  origin  totally  uninvestigated.  Still,  at  least  in 
man,  it  is  not  always  the  sensations  proper  which  form  the  foundation  of 
the  instincts,  but  also  obscure  movements  connected  with  them,  and  even 
awakened  by  them,  in  the  perception;  movements  that  are  designated  in 
part  as  feelings,  which,  however,  may  fail  to  form  distinct  representations, 
of  their  object. 

All  instincts  in  man  belong  essentially  to  the  brain,  and  not  to  the  peripheral 
nervous  system.  The  point  of  origin  of  a  given  sensation  may  lie  in  the  most 
distant  part  of  the  organism,  but  nowhere  else  can  it  affect  the  mechanism  by 
means  of  which  complicated  movements  are  realized,  nowhere  else  can  these 
obscure  perceptions  be  united  than  in  the  brain.  By  means  of  both,  however, 
these  sensations  are  transformed  into  instincts. 

One  speaks  also  of  the  mental  instincts,  intellectual,  accumulative,  family 
iuptinct,  the  love  of  children,  etc.  There  is  here  also  implied  the  necessity  to 
certain  acts,  stirred  up  by  certain  groups  of  ideas  become  persistent;  ideas, 
however,  which  do  not  proceed  from  one  another  as  single  definite  perceptions, 
but  necessitate  action  conjointly,  with  the  obscure  abstraction  of  simple  sen- 
sation. 

§  24.  In  the  appetites  and  instincts,  wherever  they  are  not  at  once 
gratified,  certain  masses  of  ideas  relative  to  the  end  to  be  attained  strug- 
gle against  the  opposing  circumstances,  and  the  relations  of  tension 
between  the  ideas  are  thereby  materially  altered.  In  this  way  the  in- 
stincts easily  excite  emotions  more  or  less  strong,  continuous,  or  transient 
(§  30);  and  in  that  the  instincts,  and  the  feelings  awakened  by  them, 
mino-le  with  the  perception,  this  already  assumes  an  element  of  move- 
ment impelling  towards  outward  objects,  and  receives  something  warm, 
sensuous:  bv  this  union  there  are  produced  quite  new  states  of  mind. 

The  relations  of  the  intercourse  of  the  sexes  offer  a  good  example  of  this. 
The  aesthetic  pleasure  in  the  society  of  an  individual  of  the  ojjposite  sex,. 
or  the  sensible  conviction  of  their  excellency,  is  first  awakened  through 
the  mingling  of  sexual  feelings  and  emotions  with  the  states  of  mind  which 
are  in  tlie  whole  termed  love,  and  which  with  the  extinction  of  the  sexual 
feelings  also  ceases. 

There  is  nothing  inconsistent  in  seeking  to  discover  in  certain  parts 
of  the  brain  the  seat  of  the  sensual  instincts.  It  must  be  in  those  parts 
where  certain  nerves  of  sensati(ui  and  their  central  expansions— for  exam- 
ple, the  vagus,  the  nerve  of  the  sexual  organs — meet  with  the  motory 
apparatus.  But  hitherto  it  has  not  been  proved,  nor  is  the  supposition 
probable,  that  these  parts  are  situated  upon  the  superior  surface  of  the 
brain. 

In  insanity,  not  only  do  the  nutrient  and  sexual  instincts  very  often  show 
themselves  in  an  uncontrolled  manner,  but  also  new  instincts  appear,  and 
frequently  of  such  a  nature  as  did  not  belong  to  the  former  life  of  the  individual. 


30  PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS. 

persistent  inclinations  to  certain  acts — as,  for  example,  the  continual  collection 
of  all  sorts  of  trifles  (feathers,  rags,  paper,  etc.);  which  reminds  us  of  the 
instincts  of  collection,  etc.,  proper  to  certain  animals,  and  whose  psychical 
origin  is  equally  peculiar  and  undiscovered.  In  general,  tlie  acts  of  the  insane, 
where  the  disease  is  manifested  chiefly  by  external  actions,  as  in  mania,  assume 
what  Jacobi  has  strikingly  called  an  instinctiform  character;  and  it  is  remark- 
able that  frequently  the  physiognomical  expression  corresponds  thereto,  expres- 
sively calling  to  mind  the  appearance  and  demeanor  of  certain  species  of 
animals. 

§  25.  Ill  the  instincts  there  are  no  single,  clear,  and  definite  ideas; 
but  there  are  no  sensations  and  feelings  which  excite  the  impulses  of 
movement,  and  whereby  the  action  of  the  motory  nervous  system  is 
directed  towards  the  groups  of  muscles.  If,  however,  the  known  and 
definite  ideas,  by  being  united  to  the  impulses  of  movement,  exercise  an 
influence  u2:)on  the  muscular  movements,  this  is  called  Will. 

This  is  at  least  the  simplest  case,  and  the  ground-work  of  the  will.  Here  the 
impulses  of  movement  proceed  no  longer  from  sensitive  irritation,  but  from 
motives;  that  is  to  say,  from  complex  ideas  present  to  the  consciousness,  although 
in  only  a  slight  degree,  the  motive  still  resembles  the  irritation  (see  Schopen- 
hauer, '  Grundprobleme  der  Ethik,'  p.  41).  Essentially  it  is  the  same  process  as 
that  of  reflex  action. 

Already  in  my  first  work  upon  psychological  matters  ('  Archiv  f .  physiolog. 
Heilkunde,'  ii.,  1843,  p.  76),  I  have  represented  the  motory  side  of  the  mental  life 
as  a  gradual  succession  of  events  following  the  same  principle,  from  the  simplest 
reflex  action  to  the  most  known  act  of  the  will,  and  have  therewith  first 
shown  this  fundamental  fact  of  all  psychical  life.  Amongst  philosophers,  we 
will  find  essentially  the  same  opinion  m  a  thinker  who  certainly  does  not  assign 
to  the  will  a  lower  place  (Schopenhauer,  '  Ueber  den  Willen  in  der  Natur,'  and 
'Grundprobleme  der  Ethik').  I  have  been  very  happy  also  to  find  the  same 
general  idea  in  the  very  valuable  work  upon  Nerve  physiology,  by  Schiff  (Lehr- 
buch  der  Physiologie).  I  have  there  also  called  attention  to  the  fact,  that 
in  insanity  much  depends  upon  derangements  in  the  normal  psychical  reflex 
action,  without  the  entire  higher  mental  life  requiring  to  be  involved  in  the 
disease.  Guislain  ('Legons  Orales,'  ii.,  1,  p.  169j  agrees  with  me  upon  this 
point. 

Those  intuitions  of  movement  associate  themselves  to  the  evident 
sensitive  perception;  but  also  into  the  perception,  which  consists  solely 
in  abstract  general  impressions  which  are  indicated  by  words  (the  intel- 
ligible perception,  §  17),  images  of  movements  can  also  enter.  These, 
however,  are  then  only  equally  obscure  general  impressions  from  large  mas- 
ses of  intuitions  of  movement,  which  still  are  not  generally  separated,  but 
are  contained  therein  bundled  together;  in  order  to  the  realization  of  the 
intelligible  perception,  this  aggregation  of  intuitions  must  go  out  in  a 
number  of  single  images  of  movements,  previously  undetermined. 

It  holds  good  in  every  case  of  abstract  desire,  as  in  the  wish  to  be  virtuous,  to 
be  successful  in  examinations,  etc. ;  that  is,  would  realize  his  idea  of  vhtue,  of 
examination.  Wherever  this  is  a  real  wish,  and  no  mere  thought,  there  is  asso- 
ciated with  the  idea  an  obscure  mass  of  still  unformed  intuitions  of  movement, 
which,  in  the  realization,  must  resolve  themselves  into  a  complicated  smgle 
desire.  The  determination  to  the  object  develops  itself  in  the  determination 
to  the  effectual  means,  and  this  finally  resolves  itself  into  numberless  single 
efforts. 

The  ideas  transform  themselves  into  effort  and  will  under  the  impulse 
of  an  internal  force,  in  which  we  recognize,  even  in  the  innermost  sphere 
of  the  life  of  tlie  soul,  the  fundamental  law  of  reflex  action.  We 
micst  will.  In  the  healthy  mind  it  urges  and  impels  the  individual  to 
express  his  ideas,  to  realize  them  in  actions,  and  thereby  to  rid  himself 
of  them.     If  this  has  taken  place,  the  soul  feels  disburdened  and  freed; 


PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  31 

by  the  act  it  relieved  itself  of  the  ideas,  and  thus  its  equilibrium  is  again 
established.  This  is  a  remarkable  fundamental  fact  of  mental  life  winch 
the  inward  experience  of  each  man  must  know.  It  shows  itself  in  the 
artist  whose  mind  for  years  is  restlessly  occuj^ied  with  the  burden  of  his 
yet  uncreated  fancy,  to  whom  the  complete  and  successful  work  is  still 
vague  and  unknown,  even  as  in  those  unfortunate  men  who,  contemplat- 
ing the  perpetration  of  some  hazardous  misdeed,  are  subjected  to  the 
most  tormenting  inward  struggles,  which,  however,  disappear  after  the 
performance  of  the  act,  and  are  succeeded  by  rest. 

There  is  also  a  memory  of  the  effort  and  of  the  will  (§  19),  a  reproduction  of 
the  intuitions  of  movement,  which,  under  certain  conditions,  reunite  with  the 
ideas.  Amongst  different  men  there  exists  great  difference  in  the  ease  and 
energy  with  which  the  intuitions  of  movement  succeed  in  their  aims,  apathy  to 
complete  absence  of  will. 

All  effort,  the  instinct  and  the  will,  form  the  centrifugal  motory  aspect  of  the 
activity  of  the  soul.  The  special  constitution  of  this  phase  of  the  soul-life  con- 
stitutes, in  a  great  measure,  that  which  is  called  the  individual  character.  These 
facts  present  a  close  analogy  to  what  takes  place  in  the  musculo-motor  nervous 
system,  while  pure  conception  has  far  more  in  common  with  the  phenomena  in 
the  nerves  of  sense.  We  find,  therefore,  in  effort  the  same  categories  which,  as 
general  expressions,  represent  certain  states  of  muscular  movemement — fatigue 
and  paralysis  of  movement  (weakness  and  paralysis  of  the  will),  tonic  convulsion 
(continued  and  determined  effort  in  one  direction  with  immovability  in  all 
others),  convulsive  movement  (instincts  let  loose  by  disease,  covetousness, 
morbid  restlessness,  forming  of  projects  and  desire  of  action).  It  is  worthy 
of  consideration,  that  frequently  in  mental  disease,  this  motoxy  side  of  the  soul- 
life  and  the  musculo-motory  function  are  both  altered  in  the  same  morbid 
manner.  Thus,  there  occurs  absence  of  will,  together  with  general  subparalysis 
of  movement,  a  morbid  exaggei-ation  of  the  will,  with  increased  muscular 
activity  (for  example,  in  maniacal  conditions);  at  other  times,  the  disease 
passes  quickly  from  the  one  sphere  to  the  other,  as  in  an  attack  of  epileptic 
convulsions,  followed  immediately  by  a  psychical  convulsive  state,  a  violent  fit 
of  mania.  Weakness  of  the  spinal  cord  is  also  frequently  accompanied  by  weak- 
ness of  will,  despondency,  and  absence  of  mental  energy. 

§  26.  But  as  the  sensations  and  feelings  are  the  more  easily  converted 
into  instincts  in  proj^ortion  to  their  strength,  so  Will  is  developed  out  of 
the  single  perceptions  the  more  easily  according  to  the  strength  and  per- 
sistence with  which  they  enforce  themselves.  On  this  account  the  strong- 
est ideas,  at  the  end  of  their  transition,  pass  forcibly  in  actions.  It  is  a 
fortunate  provision,  however,  in  mental  life  that  every  perception  does 
not  attain  to  this  degree  of  strength.  Then,  according  to  the  laws  of  the 
association  of  ideas,  there  arise  tiie  contrasting  perceptions  (§  19);  they 
draw  after  them  further  perceptions  related  to  them,  and  there  arises  in 
consciousness  a  conflict.  The  whole  mass  of  ideas  which  represents  the 
/(§  28)  comes  into  exercise,  and  gives  the  final  decision  according  as  it 
impedes  or  favors  that  first  idea.  This  opposition  in  consciousnes,  which  in 
the  end  is  decided  by  the  /,  is  the  fact  of  the  liberty  of  the  individual. 

The  assumption  of  absolute  liberty,  as  well  as  the  results  that  flow  from 
it,  is  erroneous.  The  liberty  of  an  individual  is  always  relative,  and  difl'er- 
ent  men  are  free  in  different  degrees.  Originally  the  individual  is  in  no 
respects  free;  he  becomes  so,  first,  by  being  possessed  of  a  mass  of  well 
ordered  and  easily-evoked  perceptions,  out  of  which  there  is  formed  a 
strong  kernel,  the  /.  There  are  two  general  conditions  necessary  to  the  free- 
dom of  human  action.  In  the  first  place,  an  unobstructed  association 
of  ideas  whereby,  around  the  ideas  presented,  which  are  transformed 
into  will,  other  ideas  originating  may  be  gathered,  and  may  be  opposed 
to  the  former.     In  the  second  place,  a  sufficiently  strong  /  (§  28),  that 


32  PRELIMI^'aUlY    PHYSIO-PATHOLOGICAL    OBSEKVATION8. 

can  give  the  decision  by  its  mass  of  ideas,  strengthening  one  set  of  the- 
opposing  perceptions,  and  tliereby  relatively  weakening  the  other.  With 
those  weak  in  perceptions  and  mentally  dull,  freedom  is  to  a  great  extent 
absorbed  in  the  dreamlike  monotony  of  custom.  _  The  man  of  weak 
mind  is  less  free,  since  the  living  association  is  absent  from  his 
perception,  and  opposing  ideas  are  not,  or  only  very  slowly,  awakened.  A 
child  is  less  free  as  his  perception  is  active,  since  no  strong  /  has  as 
yet  been  formed,  that  could  send  a  powerful,  firmly  combined  mass  of 
perceptions  into  the  conflict. 

In  a  medico-legal  aspect,  it  is  very  important  for  the  physician  to  have  clear 
views  upon  the  nature  of  human  hberty,  so  much  obscured  by  abstract  modes  of 
treating  the  subject.  The  contents  of  this  paragraph  are  mainly  devoted  to  this, 
purpose.  Liberty,  therefore,  consists  essentially  in  an  influencing  and  transfor- 
mation of  the  (occasional)  will :  in  (occasional)  masses  of  ideas  pressing  into  re- 
flection by  the  aid  of  other  ideas,  and  especially  by  the  entire  mass  of  combined 
ideas  belonging  to  tlie  I;  in  the  control  which  the  I  exercises  over  the  tendencies 
actually  existing  ;  therefore  in  the  possibility  of  self-command.  The  more  com- 
pact and  united  the  /  is  in  itself,  the  more  decided  is  the  character ;  on  that 
account  the  more  decidedly  does  each  one  call  into  exercise,  by  his  affirmation  or 
negation,  the  ideas  which  are  already  floating  in  the  mind.  So  is  the  saying  to 
be  understood,  that  "true  liberty  consists  in  limitation,"— namely,  by  means  of 
the  /.  Where  this  limitation  fails,  the  ideas  that  occasionally  spring  up,  often 
depending  only  on  the  sensitive  excitations  present  at  the  moment,  or  only  pass- 
ing desultorily  (capricious),  press  unhindered  towards  the  motory  side,  and  enforce 
their  accomplishment.  By  the  most  varied  bodily  influences,  however,  this 
limiting  power  of  the  I  may  be  restricted,  diminished,  or  quite  abolished. 

When  an  individual  makes  moral  motives  the  rule  of  conduct  in  his  actions, 
this  can  only  be  done  inasmuch  as  by  frequent  reproduction  and  practice  he 
unites  the  masses  of  perceptions  which  are  referable  to  his  moral  law  with  all  his 
ideas,  so  that  they,  with  every  strong  motion  of  the  thoughts,  accompany  them 
into  consciousness.  They  form  tlien  an  essential  constituent  element  of  the 
measure  of  perception  of  his  I;  and  if  a  conflict  arise  in  the  consciousness,  they 
not  only  immediately  step  forward,  but  they  also  over  all  the  contents  of  the  /, 
upon  the  whole,  have  the  advantage.  In  the  immoral  man,  on  the  other  hand, 
the  egotistical  and  malignant  thoughts  have  graiUially  so  rooted  themselves  that 
they  alwavs  are  ready  to  step  forward,  and  the  I  is  occupied  by  that  whose  chief 
mass  is,  upon  the  whole,  to  the  bad  side.  Of  course  it  is  not  supposed  that  such 
an  individual  on  this  accounb  acts  wickedly  in  every  case  ;  in  him  also  the  associa- 
tion of  ideas  is  an  active  principle,  and,  inasmuch  as  it  suggests  to  his  mmd  the 
contrasts  of  his  evil  thoughts,  half-smothered  emotions,  half -erased  images,  and 
the  remembrance  of  better  days,  with  the  good  advices  received  in  youth,  step 
into  consciousness,  and  a  violent  conflict  may  result.  In  the  end,  indeed,  the  / 
favors  the  wicked  side  ;  were  it  to  favor  the  good,  the  man  would  not  be  immoral; 
still,  he  is  a  man  whom  certainly  it  would  be  unsafe  to  trust  too  much,  altho\igh 
in  this  case  he  may  have  overcome  his  evil  desires.  The  strength  of  the  opposing- 
moral  motive  can,  however,  never  beforehand  be  estimated.  There  is  no  man 
absolutely  bad  ;  benevolent  inclinations  may  sometimes  have  the  predominance, 
in  no  human  being  are  they  totally  suppressed,  and  the  histoiy  of  criminals  shows 
how  often  that  httle  store  of  youthful  recollections,  the  remembrance  of  an  old 
saying  or  verse  of  a  song,  forcing  itself  into  tlie  train  of  thouglit,  calls  up  the 
suppressed  moral  perceptions,  and  therewith  the  impression  of  the  good  is  con- 
firmed. If  there  existed  an  individual  such  as  old  Cenci  in  Shelley's  drama,  the 
wicked  conclusion  could  with  him,  indeed,  each  time  be  predicted  as  a  result  to 
which  he  was  irresistibly  impelled  :  but  there  is  no  such  individual,  and  no  one 
who  is  mentaUy  healthy  is  compelled  to  acts  of  villany. 

§  27.  The  normal  reciprocal  action  of  the  perception,  whereby, 
through  the  ideas  actually  in  the  mind,  other  contrasting,  or  in  general 
limiting,  ideas  are  awakened,  whereby  all  proceeds  with  moderate  strength 
and  rapidity,  so  that,  in  general,  a  conflict  can  arise  in  consciousness,  so 
that  thought  and  reflection,  and  therewith  a  survey  of  past  and  future, 
are  possible,  is  best  designated  as  the  state  of  Reflection.  One  easily  per- 
ceives how  this  is  an  essential  condition  of  all  liberty. 


PRELIMINARY    PHYSIOPATHOLOGICAL    OBSERVATIONS.  33 

Now  there  are  many  states  where  this  reflection  is  weakened  or  de- 
stroyed. This  appears  to  a  greater  or  less  extent,  first,  in  the  emotions 
(§  30),  which  are  still  considered  physiological  states;  then,  in  almost  all 
patiiological  states  of  the  brain.  Alcoholic  intoxication,  sympathetic  cere- 
bral irritations,  most  of  the  deeper  organic  diseases  of  the  cerebral  sub- 
stance— in  short  all  the  diseases  of  the  brain  with  which  we  have  here  to 
do  as  mental  diseases — disturb  the  free  exercise  of  the  perception,  and 
thereby  limit,  or  completely  destroy,  the  reflecting  power.  They  effect 
this  in  many  ways;  sometimes  certain  desires  and  instincts,  through 
disease  of  the  brain,  are  directly  increased  to  excessive  intensity  (sexiial 
instinct,  destructiveness),  and  are  transformed  into  will  and  actions  Avith- 
out  any  other  ideas  being  able  to  control  them;  sometimes  all  perception 
proceeds  with  such  rapidity,  that,  in  the  confusion  of  ideas,  there  is  no 
one  so  powerful  or  lasting  as  even  to  originate  an  actual  conflict  in  the 
consciousness.  Frequently  we  see  both  these  conditions  in  the  maniacal 
states,  where,  in  the  latter  case  indicated,  the  slightest  excitation  from 
without  often  decides  the  nature  of  the  actions.  Sometimes  the  percep- 
tion is  so  sluggish,  and  the  /so  weak,  that  from  this  source  the  conditions 
of  an  internal  conflict  are  wanting;  forexample,  in  dementia.  Sometimes, 
in  consequence  of  cerebral  affection,  certain  false  connections  of  ideas, 
erroneous  conclusions,  become  so  persistent,  and  so  interweave  themselves 
with  the  whole  mass* of  ideas  of  the  /,  that  their  contrasts  are  completely 
effaced  from  the  soul,  and  they  therefore  press  themselves  into  all  con- 
clusions; and  the  /,  falsified  through  these  fixed  ideas,  is  now  forced 
always  to  decide  according  to  their  sense:  this  is  the  case  in  monomania, 
also  in  many  maniacal  and  melancholic  states.  The  determination  and 
the  deed  often  follow  in  these  cases  with  great  placidity,  and  with  ap- 
parently sufficient  deliberation  and  choice  of  means;  notwithstanding  the 
inward  reflection  is  v/anting,  because  the  false  opinions'  have  acquired  the 
strength  of  irresistiDie  motives,  and  the  patient  cannot  rid  himself  entirely 
of  them. 

In  the  above  we  have  merely  given  a  few  examples,  and  not  enumerated  all 
the  states  in  which  the  reflection  is  suppressed  in  insanity.  Much  in  the  mechan- 
ism of  the  mind  is  as  yet  entirely  unknown  ;  in  many  states  of  insanity,  of  intoxi- 
cation, etc.,  entire  great  series  of  perceptions,  the  sense  of  duty,  a3sthetic  ideas, 
etc.,  appear  to  have  disappeared  altogether  or  temporarily,  without  other  masses 
of  ideas,  by  which  the  former  were  banished,  being  allowed  to  establish  them- 
selves. 

In  all  mental  diseases  the  power  of  reflection  suffers  first,  and  therewith  the 
liberty.  Naturally,  this  loss  of  liberty  is  not  the  essential  manifestation  of  the 
morbid  process,  but  only  a  result  of  the  most  varied  mental  disorders  abstractly 
expressed  in  order  to  be  understood  ;  at  no  time  can  it  have  the  significance  of 
a  diagnostic  sign.  The  reflection  also  suffers  in  the  insane  in  very  difi'erent 
degrees.  There  are  conditions  which  cannot  be  distinguished  from  the  class  of 
mental  diseases  without  an  unnatural  separation  of  things  analogous ;  for 
example,  the  initiatory  stage  of  many  states  of  profound  nielauchoha,  which 
frequently  is  much  prolonged  and  in  which  there  still  exists  in  the  patient  a  cer- 
tain caimcity  of  reflection.  Mental  disease  and  comj^lete  absence  of  liberty  are 
therefore  not  the  same  ;  a  medical  opinion  upon  such  states  ought  not  to  embrace 
in  a  general  manner  the  abstract  ideas,  which  ought  to  be  thoroughly  distin- 
guished from  each  other,  of  either  mental  disease  or  health,  of  liberty  or  non- 
liberty,  but  it  must  trace  physiologically  the  concrete  phenomena,  the  psychical 
events,  even  to  their  source,  analyze  their  connection,  and  estimate  their  results. 
But  in  order  to  do  this,  special  education  in  this  subject  is  indispensable,  which' 
unfortunately,  is  possessed  by  few.  '  * 

This  would  be  the  proper  place  to  consider  the  question  of  imputation  and 
responsibility  :  a  full  investigation  of  this  subject  does  not,  however,  lie  within 
the  sphere  of  this  work  ;  the  leading  principles  of  its  study  are  laid  down  in  the 
3 


34  PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIOXS. 

preceding  paragraphs.  A  few  remarks  might  nevertheless  be  submitted.  When 
the  question  of  responsibility  is  raised,  it  has  always  hitherto  been  a  customary 
concession  by  the  medical  jurist  to  answer  it.  From  the  nature  of  the  question, 
however,  the  physician  is  not  obliged  to  give  any  opinion  upon  these  wholly 
juridical  matters,  but  only  to  furnish  the  judge  or  the  jury,  who  decides  these 
questions,  with  the  facts,  fully  digested,  relative  to  the  case.  Tlie  physician  can 
also,  it  it  be  his  interest,  refuse  to  answer  the  question  of  responsibility  ;  and  I 
myself  have,  in  a  celebrated  case  (Process  Fahrner,  Rottweiler  Schwurgericht, 
December,  1858),  declared  that  if  the  question  of  responsibility  were  put  to  me,  I 
would  not  answer  it,  as  being  extra  medical.  It  was  accordingly  not  put.  What 
other  question  may  then  be  legitimately  proposed  to  the  physicians  ?  Evidently, 
in  most  cases,  questions  like  the  following  : — Whether  disease  exists  which  dis- 
turbs the  mental  activity  generally,  and  specially  suspends  liberty  of  will ;  or,  as 
degrees  must  here  be  admitted,  whether  to  a  greater  or  less  extent  it  has  limited 
it,  or  could  have  done  so.  By  answering  this  question  the  physicians  keep  within 
their  own  sphere,  and  it  contains  all  the  essentials  that  can  be  learned  from  them. 
For  the  physician  who  is  a  competent  judge,  it  is  impossible  in  the  present  state 
of  science  to  give  a  definite  answer  to  this  question,  and  therefore  he  should 
declare  it,  and  without  respect  to  consequences.  He  has  no  other  interest  than 
that  of  truth,  and  thereby  should  not  intermeddle  with  matters  which  do  not 
belong  to  his  ofiice,  and  for  which  he  is  not  responsible  :  for  example,  whether 
the  law  should  punish  those  who  are  evidently  to  some  extent  insane,  or  what 
degree  of  punishment  should  be  inflicted  upon  the  accused.  The  judges  (or  jury) 
are  not  bound  by  the  opinion  of  the  medical  man,  which  is  but  one  element 
among  others  to  aid  them  in  coming  to  a  decision.  It  would  be  fearful  if  the 
medical  evidence,  often  so  bad  and  so  contradictory,  had  a  decisive  influence 
upon  the  issue  of  a  criminal  process.  It  were  "well  that  physicians  could  see  that 
hereby  the  influence  of  their  science  is  limited  ;  the  more  strictly  they  keep  to 
their  own  sphere,  into  which  none  can  follow  them,  the  greater  will  be  their 
influence.     The  author  speaks  from  forensic  experience. 

§  28.  In  the  course  of  our  lives,  in  consequence  of  the  progressive 
combination  of  the  perceptions,  there  are  formed  great  masses  of  ideas 
which  constantly  become  more  associated.  Their  peculiarity  in  individuals 
does  not  depend  merely  upon  the  special  contents  of  the  single  perceptions 
excited  by  sensitive  impressions  and  outward  events,  but  also  by  their 
habitual  relations  to  the  instincts  and  will,  and  by  the  jDersistent  restrict- 
ing or  extending  influences  which  arise  out  of  the  whole  organism:  even 
the  child  comes  to  receiye  from  his,  as  yet  comparatively  simple,  mass  of 
ideas,  a  general  impression,  then,  as  soon  as  the  material  is  sufficiently 
developed  and  strengthened,  he  begins  to  employ  an  abstract  impression, 
the  /. 

The  /  is  an  abstraction  in  which  traces  of  all  former  separate  sensa- 
tions, thoughts,  and  desires  are  contained,  as  it  were,  bundled  together, 
and  which,  in  the  progress  of  the  mental  processes,  supplies  itself  with 
new  material;  but  this  assimilation  of  the  new  ideas  with  the  pre-existing 
/  does  not  happen  at  once — it  grows  and  strengthens  very  gi'adually,  and 
that  which  is  not  yet  assimilated  appears  as  an  opposition  to  the  /  as 
a  thou.  Gradually  it  confines  itself  no  longer  to  a  single  complexity  of 
ideas  and  desires  which  represents  the  /,  but  there  are  found  several  such 
masses  of  ideas  united,  organized,  and  strengthened;  two  (and  not  only 
two)  souls  then  dwell  within  the  man,  and  this  changes  or  is  divided 
according  to  the  predominance  of  the  one  or  of  the  other  mass  of  ideas, 
both  of  which  may  now  rei^resent  the  /.  Out  of  this,  internal  contra- 
diction and  strife  may  result;  and  such  actually  occurs  within  every 
thinking  mind.  In  happy  harmonious  natures  this  conflict  is  sjDontaneous- 
ly  and  rapidly  brought  to  an  end,  since  in  all  these  various  complex  percep- 
tions, there  is  developed,  in  common,  several  general,  in  all  recurring, 
fundamental  intuitions,  still  obscure,  and  which  cannot  be  easily  expressed, 
whereby  there  is  given  to  all  the  spheres  of  the  thought  and  will  a  har- 


PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  35 

monizing  fundamental  direction.  Faith  on  the  one  hand  and  empiricism 
on  the  other  may  serve  as  examjiles  of  such  various  fundamental  directions. 
It  is  the  highest  object  of  self-education  not  only  to  acquire  such  general 
and  solid  fundamental  directions,  but  to  elevate  them  gradually  as  much 
as  possible  by  thought  into  consciousness,  and  so,  in  the  firm  possession 
of  such,  to  attain  to  the  elaborated  first  propositions  of  all  thought  and 
will  adequate  to  the  particular  individual  nature. 

At  different  times  our  /presents  different  characters,  according  to  age,  various 
duties  of  life,  occurrences,  momentary  excitations  of  this  or  that  mass  of  ideas, 
which  at  the  time  represents  the  /,  being  more  developed  than  others  and  occupy- 
ing the  foreground.  "  We  are  another  and  still  the  same."  My  /  as  physician, 
my  I  as  a  scholar,  my  sensuous  /,  my  moral  /,  etc.,— that  is  the  groups  of  per- 
ceptions, instincts,  and  directions  of  the  will  which  are  expressed  by  these  words 
—can  come  into  opposition  with  each  other,  and  repel  each  other,  at  different 
times.  Not  only  must  inconsistency  and  disorder  of  the  understanding  and  will 
result,  but  also — on  account  of  the  continued  limiting  influence  of  the  others — 
complete  want  of  energy  in  each  of  these  features  of  the  /  would  ensue,  did  not 
some  of  these  more  obscure  or  apparent  fundamental  directions  return  to  all  of 
these  spheres. 

One  of  the  most  evident,  and  in  relation  to  mental  diseases  most  instructive, 
examples  of  an  entirely  physiological  renewal  and  transformation  of  the  I  is 
afforded  by  the  mental  events  which  occur  during  the  period  of  puberty.  With 
the  awakening  of  activity  in  a  hitherto  dormant  part,  and  with  the  complete 
organic  revolution  which  then  takes  place  in  a  comparatively  short  time,  great 
masses  of  new  sensations,  instincts,  obscure  or  more  definite  pei'ceptions  and 
impulses,  come  into  consciousness.  These  gradually  pervade  the  whole  sphere  of 
perception,  and  become  constituent  permanent  parts  of  the  I.  Thereby  it  is 
thorouglily  altered  and  renewed,  and  the  sentiment  of  self  undergoes  a  radical 
change.  But,  indeed,  until  this  assimilation  is  completed,  this  penetration  and 
transition  of  the  old  /can  scarcely  take  place  without  much  pressure  on  the  con- 
sciousness and  tumultuous  agitation  ;  that  is,  not  without  great  emotion.  This 
period  of  life  is  therefore  especially  the  time  for  emotions  arising  from  within, 
without  being  excited  by  external  influences. 

§  29.  It  is  not  without  a  purpose  that  we  have  selected  this  example 
which  illustrates  insanity  by  many  analogies.  In  it  also  there  is  usually 
developed,  with  the  commencement  of  the  cerebral  disease,  masses  of  new 
sensations,  instincts,  and  perceptions,  proceeding  from  within  outwards, 
which  were  hitherto,  at  least  in  their  present  form,  unknown  to  the  indi- 
vidual; for  example,  sensations  of  great  anxiety  with  which  there  is  com- 
bined the  idea  of  persecution.  At  first  these  stand  opposed  to  the  old  /  in 
the  character  of  a  foreign  thou  often  exciting  amazement  and  fear.  Fre- 
quently their  forcible  entrance  into  the  whole  sphere  of  perception  is  felt 
as  if  it  were  the  possession  of  the  old  /  by  an  obscure  and  irresistible 
power,  and  the  fact  of  such  forcible  possession  is  expressed  by  phantastic 
images.  But  this  duplicity,  this  conflict  of  the  old  /  against  the  new 
inadequate  groups  of  ideas,  is  always  accompanied  by  painful  opposing 
sensations,  by  emotional  states,  and  by  violent  emotions.  Herein,  in  great 
measure,  lies  the  foundation  of  the  fact  taught  us  by  experience,  that  the 
first  stages  of  the  great  majority  of  mental  diseases  consist  in  predominat- 
ing affections  of  the  sentiments,  generally  of  a  painful  kind. 

If  tlie  immediate  cause  of  the  new  and  abnormal  state  of  the  percep- 
tion— the  cerebral  affection — be  not  removed,  it  becomes  fixed  and  per- 
sistent, and  because  connections  are  gradually  formed  throughout  with 
the  groups  of  perceptions  of  the  old  7,  and  since  frequently  other  masses 
of  perceptions  more  capable  of  resistance  are  completely  destroyed  and 
effaced  through  the  cerebral  disease,  the  resistance  of  the  old  I,  the 
struggle  in  consciousness,  ceases  by  degrees  and  the  motions  are  allayed. 


36  PRELIMINARY    PHYSIO-PATHOI.OGICAL    OBSERVATIONS. 

But  now,  through  these  connections,  through  that  introduction  of  abnor- 
mal elements  of  perception  and  will,  the  /itself  is  falsified,  and  has  quite 
changed  its  nature.  Then  the  patient  can  again  be  calm,  and  his  thoughts 
sometimes  formally  correct ;  but  these  abnormal  erroneous  ideas  push 
tliemselves  into  every  part  of  it  as  irresistible  premises;  because  they 
have  over  all  formed  connections,  the  patient  has  become  in  no  respect 
what  he  formerly  was,  but  quite  another  man — his  /  has  become  new 
and  false.  At  other  times  it  appears  that  several  new  groups  of  ideas, 
having  little  coherence  amongst  themselves,  are  formed,  each  of  which 
may  represent  the  /,  and  thus  the  unity  of  the  individual  may  be  quite 
lost  (many  demented  monomaniacs).  In  so  far  as  in  these  conditions  all 
emotion  has  ceased,  we  may  rightly  designate  them  simply  false  thought 
— diseases  of  the  understanding. 

In  the  preceding  remarks  we  have  expressed  in  few  words  the  ordinary  course 
of  events  in  insanity  from  its  commencement  to  its  termination  in  incurable 
dementia.  What  has  been  said  does  not,  of  course,  appty  to  every  case  ;  for 
example,  not  to  the  dementia  ensuing  immediately  after  wounds  of  the  head  ; 
and  also,  where  the  morbid  phenomena,  on  tlie  wliole,  follow  this  course,  there 
are  presented  many  intermediate  cases  and  deviations.  In  particular,  through  the 
deeper  and  further  progress  of  an  organic  brain  disease — for  example,  that  chronic 
inflammation  of  the  cortical  substance  which  ends  in  atroph}' — the  course  is  so 
curtailed,  that  dementia  ensues  so  rapidly  as  not  to  admit  of  the  formation  of  a 
new  I;  or  recovery  or  death  takes  place  before  this  can  happen.  We  shall  recur 
to  this  subject  in  the  third  book  (on  the  varieties  of  insanity). 

We  may  also  here  call  attention  to  the  great  influence  which  the  state  of  the 
former  (old)  I  must  have  in  these  conditions.  A  weak  I  will  be  sooner  subdued 
by  the  new  abnormal  perception  than  a  strong  one.  A  slow  imperceptible  pene- 
tration of  the  old  groups  of  ideas  by  the  new  will  certainly  cause  much  less 
emotion  ;  but,  inasmuch  as  it  offers  to  the  /less  opposition,  the  latter  is  the  more 
readily  subdued  and  absorbed.  The  duration  of  the  disease  is  of  all  circumstances 
the  most  important.  The  new  groups  of  perceptions  are  dangerous  to  the  1  in 
proportion  as  their  contents  are  related  to  the  old  ;  their  imion  will  then  be  easier, 
but  the  combination  of  the  two  states,  contrasted  with  the  earlier,  will  be  propor- 
tinately  less  striking.  All  these  statements  are  fully  confirmed  by  everyday 
experience. 

In  the  state  of  health,  the  various  groups  of  id3as  which  can  represent  the  / 
find  a  fundamental  element  of  unity,  above  all,  in  the  complexus  of  ideas  of  the 
body  proper.  And  if,  in  the  course  of  life,  this  physical  sensation  of  self  is  in 
various  ways  subject  to  change  (disease,  age,  etc.),  so  does  the  joint  perception  of 
the  same  body  serve  as  a  point  of  union  for  the  remaining  preceptions,  and  as  a 
centre  from  which  the  motory  acts  jjroceed.  But  there  are  abnormal  conditions, 
particularly  in  mental  disease,  in  which  the  general  bodily  feeling  quickly  and 
sensibly  changes,  so  that  hereby  this  fundamental  sensuous  element  of  the  old  / 
undergoes  a  total  transformation.  Then  for  the  first  time  does  the  patient  lose 
his  former  personality  ;  this  he  no  more  recognizes  as  his  distinguishing  feature 
— then  for  the  first  time  the  patient  considers  himself  a  difi'erent  person  than  he 
actually  is.  It  is  very  essential  to  distinguibh  this  from  those  changes  which  the 
/undergoes  through  simple  occupation  by  new  ideas  and  aims,  produced  by  the 
disease  of  the  brain,  without  essential  change  in  the  physical  sensation  of  self. 

§  30.  A  simple  difference  in  the  perception,  familiar  to  all,  consists 
in  this — that  it  sometimes  proceeds  quietly  as  calm  imagination  or 
thought,  while  at  others  it  is  accompanied  by  great  disturbance,  by  a 
general  state  of  mental  disquietude.  In  the  first  case,  the  masses  of 
perceptions  which  represent  the  /  act  towards  the  thought  which  is 
present  in  the  consciousness  as  quiet  onlookers,  as  in  being  perceived 
they  are  only  feebly  and  slowly  changed  by  it,  and  when  obscure 
opinions  thereby  result  relating  to  the  demands  or  limitation  of  the 
/  (pleasure  or  displeasure),  these  also  are  of  but  slight  intensity.  In 
the  second  case,  any  striking  occurrence  in  the  consciousness,  as  a  mass 


PKELIMINABY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  37 

of  perceptions  suddenly  presented,  or  a  sudden  urgent  desire,  enters  with 
violence.  By  these  occurrences,  separate  groups  of  perceptions  are 
promptly  evoked,  which  bring  others  along  with  them;  whilst  others  are 
rapidly,  but  not  without  opposition,  repelled,  and  the  /  must  neces- 
sarily be  affected  by  them  pleasurably  or  painfully  according  as  they  pro- 
mote or  impede  it. 

Those  obscure  opinions,  psychical  pleasure  or  pain  (§  21),  constitute  the  founda- 
tion of  our  moral  sentiments,  Tlie  sentiments'  are  completely  bound  to  the 
ideas,  and  by  tliem  exclusively  we  are  made  aware  of  the  relations  of  tension  and 
movement  in  certain  perceptions,  of  the  degree  of  free  movement,  and  of  pro- 
moting or  impeding  influences  within  them,  and  of  the  nature  of  their  reciprocal 
action.  The  perceptions  themselves  whose  relations  of  movement  are  thus  made 
known  to  us  may  be  perfectly  clear  and  strong,  but  they  may  also  be  very  obscure 
and  their  contents  not  easily  distinguishable.  Frequently,  and  especially  in 
physical  influences  on  the  disposition,  we  are  unable  certainly  to  distinguish  the 
cause  of  the  feeling,  of  pleasure  or  pain.  Sentiments  such  as  have  no  definite 
object  presented,  and  such  as  are  of  a  depressed  irritated  nature,  often  call  forth 
merely  a  change  in  the  bodily  states.  Sickness  usually  changes  completely  our 
mode  of  feeling ;  it  modifies  not  only  the  contents  of  our  ideas,  but  also  their 
relations  of  tension  and  movement.  Conversely,  strong  feelings,  when  they  pro- 
ceed from  the  perceptions,  are  usually  accompanied  by  marked  changes  in  the 
dormant  masses  of  bodily  sensation.  Thus  many  powerful  feelings  are  half  cor- 
poreal and  half  mental  (anxiety,  fright,  etc.;. 

Emotion  may  accompany  calm  thought :  scientific  thought  can,  for  example, 
w^hen  the  allied  ideas  meet  in  a  favorable  manner,  be  accompanied  by  a  sense  of 
pleasure,  by  the  feeling  of  success.  But  the  emotions  are  much  more  lively  when, 
through  a  sudden  change  occurring  within  the  consciousness,  the  masses  of  ideas 
belonging  to  the  /  fall  into  violent  oscillation,  and  the  /  thereby  suffers  an  abrupt 
or  restless  change.  These  affections  of  the  /  are  called  the  emotions :  in  the  first 
case  they  are  joyful,  in  the  second  of  a  sad  nature.  In  all  the  sentiments, 
emotions  occur  as  essential  constituents,  although  every  sentiment  does  not 
occasion  emotion.  There  are  sentiments,  more  lasting  and  stable,  which  have  no 
emotion,  as  the  sentiments  of  self,  country,  family.'^  The  sentiment  of  the  /can 
proceed  even  to  instantaneous  suppression  ;  one  becomes  "  out  of  himself." 

As  in  the  emotions,  only  the  relations  of  tension  and  movement  in  certain 
masses  of  perceptions,  and  the  manner  in  which  the  I  is  excited  by  these  events, 
come  into  consciousness  ;  so  they  have  no  definite  existence  that  can  be  expressed 
in  words,  but  they  call  forth  desires,  and  are  in  turn  evoked  by  them.  The  senti- 
ments, since  they  consist  of  rapid  changes  in  the  relations  of  tension  and  move- 
ment in  the  perceptions,  are  naturally  always  bound  to  the  emotions. 

Music  excites  in  many  individuals  intense  emotion,  and  affords  a  very  good 
example  of  the  half  bodily,  half  mental,  states  of  this  kind.  Here,  certain  changes 
in  the  sensations  of  sound  act  immediately,  and  principally  (almost  unconsciously 
to  the  individual)  upon  the  internal  impulses  of  movement  for  great  extended 
muscular  actions  (cadence,  rhythm,  melody),  but  so  feebly  that  usually  no  move- 
ment is  produced.  This  constant  cliange  in  the  internal  impulses  of  movement 
(ideas  of  movement),  with  its  tensions  and  relaxations,  produces  nothing  but 
sentiments,  and  indeed  of  an  aimless  kind  ;  it  presents  something  inexpressible 
and  highly  superficial,  without  at  all  enriching  the  mind  with  clear  perceptions 
or  ideas.  Nevertheless,  this  excitation  of  the  sentiments  need  not  on  this  account 
be  either  worthless  or  indifferent  to  the  soul ;  it  can  contain  much  that  is  fitted 
to  soothe,  impel,  or  excite  the  present  disposition,  and  thus,  indirectly,  expand  or 
contract  the  soul  itself. 

The  dispositio7i  to  which  these  events  are  attributed  as  movements 
(emotions)  bears  an  essential  relation  to  the  motory  side  of  the  soul-life, 
to  the  instincts  and  the  will.  Not  only  are  instincts  and  impulses  of  the 
will  awakened  by  all  emotional  states  in  order  to  oppose  the  limitation  or 
advance  the  promotion,  but  also  observation  shows  that  the  production 

'  Stiedenroth,  '  Psychologie,'  ii.,  p.  2  ff.;  Volkmann,  '  Psychologie,'  p.  301  ff. 
2  Herbart,    'Lehrbuch.'      1816,  p.   54.    Drobisch,   '  Empirische   Psychologie,' 
1842,  p.  20.5. 


38  PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS. 

of  the  affections  proceeds  more  easily  from  the  motory  side  of  the  soul-lif& 
than  from  simple  pure  thought. 

Restrained  or  expanded  effort  affects  the  J  much  more  than  the  same  condi- 
tions in  pure  perception,  and  tlie  most  sudden  and  violent  agitations  result  from 
the  sudden  arrest  of  efforts  in  progress.  When,  for  example,  our  calm  scientific 
thought  is  impeded  by  an  unexpected  extei-nal  hindrance,  we  may  indeed  be 
annoyed;  but  when  our  will  is  opposed,  when  the  execution  of  plans  designed 
and  determined  by  the  /  is  hindered,  this  excites  much  more  violent  emotions — 
anger,  disappointment,  etc.  We  frequently  observe  that  thwarted  plans  and 
determinations  of  the  will — for  example,  an  occupation  enforced  while  all  the 
inclinations  of  the  individual  are  directed  towards  engagements  of  quite  a  different 
nature—become  the  causes  of  lasting  emotions,  and  of  insanity  thereby  developed. 
We  know  the  case  of  a  man  who  became  insane  because  he  was  forced  to  be  a 
butcher,  while  he  desired  to  become  an  ecclesiastic.  Examples  of  this  kind  are 
to  be  found  in  all  asylums. 

§  31.  The  question,  what  projDerly  sjoeaking  the  affections  and  the 
sentiments  are,  and  what  position  they  hold  in  the  mental  life,  is  of  great 
importance  to  the  understanding  of  insanity  (which  so  frequently,  and  for 
so  long  a  time,  consists  principally  of  a  disorder  of  the  affections).  Our 
perception  and  effort  are  always  subject  to  progressive  change;  we  only, 
however,  speak  of  a  sentiment,  when  the  mass  of  perceptions  which  repre- 
sents the  /  is  subjected  to  a  violent  shock  and  brought  into  collision, 
which  (§  30)  never  can  occur  without  emotion.  In  this  disturbance  of 
the  tranquillity  of  the  mind,  there  is  no  further  agitation  than  that  of  the 
wonted  calm  which  our  /maintains  towards  the  perceptions  j^resent,  than 
of  the  manner  in  which,  above  all,  the  multifarious  masses  of  perceptions 
and  efforts  which  we  feel  within  us  behave  towards  each  other.  This 
usual  tranquillity  is  not,  however,  absolute  quiet  or  inactivity,  but  is  the 
result  of  regulated  moderate  activity,  which  simultaneously  represents 
the  acquired  amount  of  mental  power  and  the  ordinary  direction  of  the 
mental  life;  it  may  be  called  the  mental  tone.'' 

The  tonicity  of  the  spinal  cord,  which  is  evinced  in  the  muscles,  in  the  cellular 
tissue,  etc.,  as  a  moderate  habitual  degree  of  contraction,  and  on  the  side  of 
sensation  as  a  moderate  degree  of  sensitivity  and  irritability,  is  the  product,  not 
of  a  single  sensation  or  movement,  but  of  the  sum  of  the  sensations  and  imi3ulses 
of  movement  which  is  lost  in  the  unity  and  generality  of  a  moderate  irritability. 
It  depends  upon  a  moderate  amount  of  excitation,  which  is  the  combined  result 
of  the  separate  central  nerve-acts.  This  moderate  degree  of  apparent  quiet  is  not 
broken  or  destroyed  as  a  whole  by  every  sensation  and  movement,  but  it  becomes 
so  by  all  sudden  and  strong  sensations  and  movements  (exhaustion,  pain,  etc.). 
In  both  domains  the  tonicity  is  naturally  sometimes  more  unsettled  and  variable 
than  at  others ;  indeed,  according  to  the  state  of  the  organ,  the  slightest  irrita- 
tion can  at  times  excite  fatigue,  pain,  or  convulsions;  even  a  fly  upon  the  w^all 
can  be  a  source  of  annoyance.  It  is  not  the  customary  view,  and  it  would  be  too 
vague,  although  quite  correct,  to  consider  tetanus  convulsions,  etc. ,  as  changes 
in  tonicity  (one-sided  increase,  interruption,  etc.);  undoubtedly  also  it  suffers 
from  the  disturbance  present.  Likewise  in  the  parallel  mental  states  (mental 
pain,  mental  convulsions)  the  disturbance  of  the  sentiments  is  the  most  striking; 
and  it  is,  in  general,  in  this  sense  that  we  speak  of  the  disorder  of  the  emotions 
and  of  their  priority  in  insanity. 

We  call  the  man  iinpressible,  whose  /  is  easily  moved,  and  in  whom,, 
accordingly,  agreeable  or  disagreeable  feelings — sympathy,  compassion, 
benevolence,  aversion,  etc. — are  readily  excited.  Agreeable  as  is  this, 
characteristic,  yet  this  danger  follows,  that  the  sentiments  willingly 
attach  themselves  to  these  obscure  excitations,  so  that  they  do  not  suc- 

'  Compare  the  author's  essay,  '  Aufsatz  iiber  psych.  Reflexactionen,'  loc.  cit., 
p.  95. 


PRELIMINAKY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  39 

ceed  each  other  in  a  clear  train  of  thought,  and  that  the  habit  of  clear 
thinking  is  lost,  and  the  individual  governed  by  mere  sentiment,  of  whose 
influence  he  cannot  divest  himself,  but  thereby  orders  his  actions  and 
frames  his  life.  This  is  the  impressible  character  in  the  bad  sense.  He 
is  called  unimpressible,  whose  /  is  not  easily  affected  by  pleasure  or  pain, 
either  on  account  of  great  weakness  and  dulness  of  all  the  mental  powers 
(apathetic,  very  phlegmatic  men),  or  because,  upon  contact  of  the  /with 
the  perception  present,  there  is  simultaneously  produced  distinct  opinions 
in  clear  ideas  instead  of  obscure  sentiments  (intelligent  men).  The  man 
is  strong-minded,  in  whom  there  is  developed  a  firm  tone  of  mind,  who  is 
not  immediately  moved  by  every  mental  excitation;  he,  indeed,  feels  events 
as  agreeable  or  disagreeable,  and  they  are  accompanied  by  obscure  opinions 
relating  to  the  promotion  or  hindrance  of  the  /;  but  the  /itself,  however, 
is  not  so  easily  shaken ;  he  is  not  easily  subject  to  general  mental  dis- 
quietude, to  anger  and  ill-humor,  and  in  joy  and  pain  moderation  is 
maintained.  There  is,  on  the  other  hand,  weakoiess  of  mind,  where  re- 
actions of  the  /,  extended,  but  wanting  in  energy,  are  easily  evoked; 
nearly  every  perception  excites  a  sentiment;  joy  and  sadness  succeed  each 
other  with  the  utmost  ease,  and  emotions  become  necessary  to  mental  life: 
the  diminished  sensibility  then  frequently  demands  new  and  strong  irri- 
tation, as  finding  pleasure  in  shocking  and  fearful  events,  and  the  /is  at 
rest  only  in  times  of  exhaustion  and  sleej). 

It  is  easy  to  recognize  the  identity  of  the  last -mentioned  case  with  what,  in 
the  sensitive  niotory  sphere,  is  called  irritable  weakness,  and  is  considered  the 
most  important  disposition  and  fundamental  state  in  many  nervous  diseases  (for 
example,  the  spinal  neuroses).  This  state  is  well  called  weakness,  since  with  the 
single  and  one-sided  increase  of  excitability  there  is  accompanied  an  absolute 
diminution  of  power  in  the  functions.  In  convulsions,  the  voluntary  muscular 
movement  is  weak;  in  constant  emotion,  the  thought  and  the  will  are  ^veak  and 
languid.  These  states  are  not  only  very  frequently  combined  with  each  other,  as 
in  the  tendency  to  emotion  and  the  increased  tendency  to  convulsions  in  many 
hysterical  persons,  but  they  also  very  often  originate  simultaneously  in  both 
spheres  from  the  same  causes,  have  in  their  course  the  same  consequences,  and 
the  principles  of  their  treatment  are  throughout  analogous. 

§  32.  Upon  the  nature,  method,  and  facility  with  which  the  /  is  af- 
fected in  the  form  of  emotions  and  sentiments,  depends  certainly  a  con- 
siderable part  of  the  modes  of  reaction,  and  therewith  the  individual 
peculiarities  of  men.  In  so  far  as  the  peculiar  modes  of  the  individual 
lie  in  the  inner  world  of  the  disposition,  and  this  is  not  opposed  by  the 
versatility  of  the  mental  states,  the  peculiar  manner  in  which  this  change 
proceeds  is  the  characteristic;  it  is  this  which  gives  the  fundamental  com- 
plexion and  tone  to  our  disposition.  The  disposition  is  a  certain  mode 
of  behavior  of  the  /,  the  fixed  steadfast  kernel  of  our  individuality,  Avith 
which  the  results  of  our  whole  mental  history  are  associated.  This  may, 
indeed,  be  shaken  in  the  emotions,  but  not  impaired  or  destroyed ;  what  else 
can  be  affected  in  the  emotions  than  that  group  of  ideas,  the  I?  The  / 
can  be  detached,  and  completely  destroyed,  in  serious  disorganizations  of 
the  brain  (in  dementia);  it  may  succumb,  and  a  new  one  arise  in  its  place 
(monomania);  but  even  this  is  only  the  case  (§  29)  when  the  emotions 
which  necessarily  accompany  the  lesion  and  destruction  of  the  old  /have 
been  completely  pacified. 

The  nature  and  the  manner  in  which  the  mass  of  ideas  representing 
the  /Ts  affected  by  what  passes  within  the  consciousness,  or  presses  into 
it,  determines  the  nature  and  manner  of  the  self-sensation.  Moderate 
and  lasting  changes  of  consciousness  are,  again,  the  foundation  of  the 


40  PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS. 

various  modifications  of  the  dispositions;  when  they  take  place  suddenly 
and  energetically,  and  are  accompanied  by  considerable  disturbance  of 
the  mental  equilibrium,  they  constitute  the  foundation  of  the  mental 
affections.  The  objects  of  consciousness  can  only  be  of  a  twofold  nature, 
pleasurable  or  painful;  the  one,  when  the  groups  of  perceptions  of  the  /, 
the  interest  of  our  inner  life,  are  favored  and  advanced,  through  the 
events  in  consciousness,  in  their  free  course,  their  adequate  relations,  and 
especially  in  their  transition  into  efforts;  the  other,  when  hereby  they  are 
repressed,  subverted,  and  limited.  From  the  slightest  changes  in  the 
disposition  up  to  the  most  violent  emotion,  only  two  kinds  are  possible: 
either  a  state  of  furtherance  and  expansion  of  the  /,  which  affords  pleasure, 
therefore  it  is  in  harmony  with  the  new  occurrences  in  consciousness,  and 
seeks  to  retain  them;  or  a  state  of  limitation  and  depression,  where  the 
group  of  perceptions  of  the  /,  in  their  flow  and  transition  into  effort,  are 
impeded  and  repressed,  sometimes  take  to  flight,  sometimes  perseveringly 
strive  to  enter;  here  the  /is  in  negative  relation  to  a  new  perceptions. 
Accordingly,  all  the  dispositions  and  emotions  divide  themselves  info  two 
gi'eat  classes — the  expansive  (and  at  the  same  time  affirmative),  and  the 
depressing  (and  at  the  same  time  negative,  accompanied  by  abhorrence). 
To  the  one  belong  joy,  gladness,  pleasure,  frolic,  hope,  humor,  merriment, 
etc. ;  to  the  other,  anger,  malice,  dejection,  sadness,  sorrow,  shame,  fear, 
horror,  etc. 

This  relation  is  the  basis  of  the  classification  of  those  states  of  insanity  where 
affections  of  the  disposition  predominate,  therefore  of  the  primary  forms  of 
mental  diseases  (§  29;.  "We  meet  with  two  principal  classes:  in  the  one,  the  cliief 
disturbance  consists  in  depressive  negative  dispositions  and  emotions — all  melan- 
cholic conditions;  in  the  other,  they  consist  in  expansive  affirmative  emotions — 
monomania.  We  have  not  yet  spoken  of  anger:  it  occupies  an  intermediate 
place  between  the  two  kinds  of  emotions,  viewed  in  relation  to  its  causes,  it 
belongs  rather  to  the  first,  in  that  it  implies  an  invasion  of  the  I;  but  there  fol- 
lows a  violent  reaction,  a  lively  expansion  and  explosion  of  the  perception  and 
effort,  by  which  this  hostile  impression  is  overcome,  and  the  equilibrium  again 
established.  The  conditions,  however,  wliich  are  understood  by  the  term  mania 
are,  according  to  their  psychological  nature,  intimately  related  to  anger,  and 
nosologically  their  proper  place  is  between  melancholia  and  monomania. 

§  33.  An  important  circumstance,  which  clearly  distinguishes  the 
emotions  from  calm  thought,  is  this — that  in  the  former  other  organic  pro- 
cesses besides  the  celebral  are  always  involved.  The  heart's  action,  the 
respiration,  the  digestion — the  secretions  of  the  skin,  the  liver,  and  the 
kidneys — are  altered  in  the  emotions.  In  anger,  the  facial  veins  congest; 
occasionally  it  seems  as  if  violent  emotion  would  suffocate.  Fright  and 
horror  quickly  excite  watery  secretions;  in  grief,  tlie  respiration  is  pro- 
longed and  superficial,  and  must,  therefore,  be  occasionally  broken  by 
deep  gasps  and  sighs.  It  is  thus  that  the  emotions  and  emotional  states, 
originally  by  excitation  of  the  nervous  system  coming  from  the  brain,  give 
rise  to  abnormal  physical  states.  Emotion,  wdien  transitory,  and  occur- 
rino-  in  a  previously  healthy  organism,  is  speedily  calmed;  where,  however, 
bodily  disease  is  already  present,  and  where  the  causes  are  long  continued 
(for  example,  prolonged  sadness),  there  gradually  arise  many  complicated 
disorders  of  the  organic  mechanism,  which  the  simple  cessation  of  the 
emotion  cannot  as  "quickly  terminate;  and  these  disorders  can  noAV,  by 
means  of  new  secondary  irritation  of  the  brain,  not  only  maintain  and 
increase  the  existing  emotion,  but  also  orginate  new  conditions  of  a  sim- 
ilar nature. 

For,  it  is  a  fact  taught  us  by  experience,  that  when  the  mental  func- 


PRELIMINARY    PHYSIO-PATHOLOGICAL    OBSERVATIONS.  4:1 

tion  of  the  brain  is  influenced  by  the  organic  processes  (respiration,  diges- 
tion, etc.),  this  does  not  immediately  tiSect  the  sphere  of  clear  percep- 
tion; it  does  not  thereby  follow  that  we  receive  new  thoughts,, but  rather 
that  there  originate,  in  the  first  place,  within  us  obscure  modifications  of 
self-consciousness  and  disposition,  feelings  of  furtherance  and  limitation 
of  our  mental  function,  and  thereby  an  essential  element  of  emotional 
states  is  forced  upon  us  (§  20). 

Examples  of  this  are  met  with  in  many  diseases.  We  very  often  see  that  in 
those  afflicted  with  heart  disease  anxiety  appears,  and  that  in  diseases  of  the 
intestines,  in  changes  in  the  blood  resulting  from  icterus,  sullen,  anxious,  irri- 
table moods,  sluggishness  of  thought,  general  disharmony,  etc.,  are  observed. 
The  feeling  of  corporeal  well-being  or  of  bodily  illness  generally  exercises  a  great 
influence  upon  the  frame  of  mind,  whether  it  be  glad  and  cheerful,  or  depressed 
and  sad;  should  external  causes  capable  of  exciting  an  emotion  now  influence  us, 
very  much  depends  upon  these  existing,  habitual  or  transient,  cerebral  states 
which  are  excited  by  the  bodily  conditions,  whether  the  emotion  will  be  constant. 
In  an  individual  already  irritated  by  bodily  disease,  an  emotion  excited  by  any 
external  cause  becomes  sooner  fixed,  and  is  more  lasting  in  its  effects,  than  when 
it  originates  in  a  man  who  enjoys  the  best  ijhysical  health  and  joyful  disposition. 

These  relations  constitute  some  of  the  most  important  fundamental  elements 
of  the  pathology  of  insanity.  They  are  the  key  to  a  knowledge  of  the  predispo- 
sition to  mental  diseases  resulting  from  the  most  diverse  bodily  diseases,  and  of 
the  mode  of  action  of  psychical  causes.  The  latter  very  seldom  (see  2d  book) 
produce  insanity  directly;  they  do  so  much  more  frequently  secondarily  through 
the  interposition  of  other  disorders;  for  example,  in  this  manner — that  through 
long-continued  grief  the  nutrition  greatly  suffers,  and  this  primarily  exerts  an 
influence  upon  the  brain  and  thereby  upon  the  psychical  processes. 

§  34.  In  the  emotions  calm  deliberation  is  impossible.  The  /  itself, 
having  fallen  into  a  vacillating  and  disturbed  condition,  does  not  possess 
the  composure  necessary  to  consider  the  facts  present  in  consciousness 
with  sufficient  concentration  and  attention.  That  state  in  which  this 
consideration  is  possible,  and  actually  takes  place,  is  called  the  reason. 
In  order  to  this  consideration,  and  therefore  also  to  deliberation,  there  is 
requisite  a  reciprocal  definitencss  of  the  perceptions,  leisure  and  delay, 
composure  and  reflection.  The  contrastuig  perceptions  (§  2G)  must  be 
capable  of  becoming  effective,  and  requisite  calm  must  be  afforded  to  the 
/.  Neither  of  these  occur  in  mental  disease.  Through  the  cerebral 
affection,  dispositions  and  instincts  are  produced  which  become  points  of 
origin  of  emotions.  If  out  of  these,  again,  false  opinions  arise,  they  can- 
not be  rectified,  and  the  patient  cannot  see  his  error;  at  first,  because  the 
persistent  emotions  do  not  permit  the  calm  necessary  to  allow  the  con- 
trasting perceptions  sufficiently  to  develop  themselves,  and  the  longer  it 
continues  the  more  doits  results,  the  false  judgments,  become  fortified  and 
consolidated;  later,  however,  because  tliose  false  judgments  have  become 
integral  fundamental  parts  of  all  the  groups  of  ideas  of  the  /. 

In  every  fully  developed  mental  disease  it  is  therefore  impossible  for  the 
patient  to  recognize  the  falseness  of  the  morbid  perceptions.  This  fact  is  con- 
founded to  a  very  great  extent  with  loss  of  reflection,  spoken  of  in  §  27.  But  by 
that  even  the  insane  have  also  lost  their  reason,  and  on  the  ground  so  well  stated 
by  Herbart,  that  "  their  thoughts  do  not  admit  of  being  disturbed  in  their  special 
course  by  means  of  external  or  internal  opposition."  Also  in  health,  all  kinds  of 
caprices,  false  opinions,  foolish  thoughts,  pass  through  the  brain;  but  one  can, 
if  he  be  not  actually  in  a  state  of  emotion,  calmly  accept  or  reject  them. 

§  35.  Kecovery  from  insanity  ordinarily  takes  place  only  in  the  primary 
period,  which,  however,  often  continues  for  a  series  of  years,  during 
which  it  principally  depends  on  emotional  states.  Inasmuch  as  through 
removal  of  the  disease  of  the  brain,  or  of  its  more  remote  organic  causes, 


42  PRELIMINARY    PHYSIO-PATHOLOGICAL   OBSERVATIONS. 

the  morbid  dispositions  and  emotions  disappear,  the  false  judgments 
which  were  bused  upon  it  must  likewise  disappear,  and  the  group  of  per- 
ceptions of  the,  now  no  longer  shaken,  /  enter  immediately  into  their  old 
direction.  Should,  however,  the  organic  causes  of  the  cerebral  disease 
not  have  been  removed  until  the  false  opinions  have  entered  into  mani- 
fold combinations  with  the  groups  of  perceptions  of  the  /,  the  patient 
may  certainly  recover;  but  his  recovery  will  be  a  longer  and  much  more 
gradual  psychological  process,  until,  through  strengthening  of  the  former 
normal  direction  of  the  thoughts,  the  connections  which  the  false  opinions 
had  contracted  with  the  /,  gradually  loosen,  and  eventually  are  entirely  dis- 
solved. Many  convalescents  do  not  recover  completely  until  they  return 
to  their  homes  and  to  their  former  relations  of  life,  employments,  etc. 
When,  however,  the  old  /  is  vitiated,  corrupted,  and  falsified  on  all  sides 
by  the  morbid  false  ideas — when,  besides,  the  group  of  perceptions  of  the 
former /is  so  completely  repressed  (forgotten),  that,  without  any  trace 
of  emotion,  the  patient  has  exclianged  his  whole  personality,  and  has 
scarcely  any  remembrance  of  it,  then  recovery  is  next  to  impossible,  and 
only  occurs  in  rare  cases  through  excitation  of  violent  emotions,  and 
thereby  through  a  kind  of  mechanical  training  (as  attempted,  for  exam- 
ple, by  Leuret '),  continuously  to  repel  tlie  appearances  of  the  insanity. 
Naturally,  this  can  only  be  attempted  where  the  brain  has  not  as  yet  sus- 
tained any  deep  organic  lesion:  where  this  is  present,  as  in  many  of  these 
states,  especially  in  secondary  dementia,  all  hope  of  recovery  is  past. 

1  Du  Traitement  moral  de  la  Folie,'  Paris,  1840. 


THE    ELEMEKTAKY    DISORDERS    IN    MENTAL   DISEASE.  43^ 


CHAPTER  IV. 

THE  ELEMENTARY   DISORDERS  IN  MENTAL  DISEASE. 

§  36.  Previous  to  the  consideration  of  those  complex  groups  of 
symptoms  which  constitute  the  special  forms  of  mental  disease,  there 
are  some  general  relations  which  require  to  be  briefly  noticed;  especially 
the  separate  elementary  disturbances  which_  are  always  found,  dift'erently 
grouped  together,  in  the  various  forms  of  insanity  (melancholia,  mania, 
etc.).  In  those  cerebral  afEections  which  come  under  consideration  as. 
mental  diseases,  there  are,  as  in  all  others,  only  three  essentially  distinct 
groups — namely,  sensitive,  motory,  and  mental  (perceptive)  anomalies. 
Thus,  according  to  this  threefold  division,  we  have  to  consider  succes- 
sively each  of  the  three  leading  groups  of  elementary  disturbances — intel- 
lectual insanity,  emotional  insanity,  and  insanity  of  movement. 

Of  all  these  states,  the  mental  disorders  are  certainly  the  most  striking,  the 
most  characteristic,  and  those  upon  which  the  diagnosis  is  based;'  but  we  must  not 
consider  that  the  sensitive  and  motory  morbid  processes  are  only  accessories. 
The  anomalies  of  sensibility  play  an  important  part  in  insanity;  disorders  of  what 
we  call  the  imagination  (§  18)  extend  over  a  great  part  of  its  sphere;  and  the 
anomalies  of  movement  which  at  first  sight  seem  quite  foreign  to  insanity,  form, 
as  we  shall  afterwards  see,  some  of  the  most  weighty  points  of  anatomical  diag- 
nosis and  of  prognosis. 

SECTiO]sr  I. — The  Elementary  Intellectual  Disorders.'' 

§  37.  The  essential  characteristic  of  insanity,  that  which  distin- 
guishes it  as  a  morbid  state,  consists  chiefly  in  the  fact  that  certain  states 
of  the  brain — certain  dispositions,  feelings,  emotions,  opinions,  determi- 
nations— proceed  from  within  outwards,  owing  to  disease  of  the  organ  of  the 
mind;  while,  in  the  healthy  state,  our  emotions,  opinions,  determinations, 
originate  only  upon  sufficient  external  motives,  and  on  that  account  also 
stand  in  a  certain  harmonious  relation  to  the  external  world.  No  one 
wonders  if  any  one  who  had  sustained  a  great  loss  is  sad,  if  another  to  whom 
an  earnest  wish  has  been  fulfilled  manifests  exuberant  joy;  but  we  rightly 
consider  it  as  a  morbid  symptom  when  an  individual  without  any  exter- 
nal motive  is  depre:sed  with  sadness  or  elated  with  joy,  or  even,  where 
some  external  cause  has  been  given,  the  individual  is  immoderately  or  for 
too  long  a  time  affected  by  it,  as  when  a  trifling  occurrence  excites  an 
individual  to  violent  rage  which  he  is  unable  for  a  long  time  to  restrain. 

According  to  the  same  fundamental  principle,  we  judge  of  all  events  in  the 
nervous  system.  Fatigue  after  a  long  march  is  normal;  persistent  weariness  alter 
sufficient  rest  is  morbid.  A  shivering  sensation  experienced  when  the  air  is  cliili 
is  normal,  the  sensation  of  cold  when  the  external  temperature  is  high  is  morbid. 

'  In  considering  the  mental  anomalies,  it  is  necessary  to  allude  to  much  in  the 
previous  section  which  will  not  be  again  repeated.  For  the  elucidation  of  certain 
points  which  are  therefore  but  cursorily  mentioned,  the  reader  may  refer  to 
§§  18-35;  there  is  much,  however,  which  cannot  be  properly  explained  till  we 
come  to  describe  the  various  forms  of  insanity. 

2  For  the  paragraphs  immediately  following  see  Zeller's  'Remarks  upon 
Guislain's  Phrenopathie. '    Stuttg.,  1838. 


44  THE    ELEMENTAKY    DISOEDEES    IN    MENTAL    DISEASE. 

Numbness  of  the  leg  from  pressure  upon  the  nerves  is  certainly  slightly  morbid, 
but  it  is  normal  when  compared  with  persistent  numbness  due  to  an  internal 
cause,  as  disease  of  the  spinal  cord.  .So,  too,  the  condition  is  morbid  when  a 
slight  cause  excites  disproportionately  violent  reaction -if  walking  a  few  steps 
causes  fatigue,  or  when  a  gentle  breeze  excites  shivering.  In  these  respects, 
however,  the  limits  of  disease  and  health  are  by  no  means  clearly  defined,  since 
there  are  many  states  of  this  description,  especially  such  as  are  transient,  that 
are  not  ordinarily  considered  as  diseases.  A  glass  of  wine  can  elevate  our  spirits 
"without  external  cause  for  joy.  Here,  by  means  of  the  alcoholic,  a  cerebral 
state,  an  expansive  disposition,  is  induced  from  within  outwards;  a  weak  analogy 
to  insanity,  which,  however,  no  one  has  designated  a  disease,  as  it  quickly  passes 
off  without  any  durable  effect. 

Very  much  depends  iTpon  the  duration  and  intensity  of  the  phenom- 
ena, whether  we  consider  tlie  mental  state  as  morbid.  Every  one  knows 
from  personal  experience,  that  occasionally  there  may  originate  in  us, 
without  outward  motive,  dispositions  lively  or  sad,  tender  or  bitter — 
states  of  mind  whicli  arise  out  of  slight  changes  in  the  organic  processes, 
and  only  recognizable  by  careful  attention.  These  dispositions  are  not 
morbid  when  moderate  and  of  short  duration,  and  thoroughly  subject  to 
the  control  of  the  mass  of  perceptions  of  the  /;  Ij^it  they  are  morbid  when 
they  constantly  and  in  every  matter  intrude  themselves  on  the  individual, 
when  they  can  no  longer  be  removed  by  outward  mental  excitation,  and 
when,  instead  of  being  controlled  by  the  group  of  perceptions  of  the  /, 
they  affect  us  tumultuously  and  excite  a  lasting  state  of  painful  internal 
disquietude.  As  with  such  dispositions,  so  also' is  it  with  single  distinct 
perceptions.  A  strange  or  foolish  thought  may  pass  through  the  mind  of 
the  most  rational  man;  if  only  it  does  not  lodge  there,  but  is  by  a  power- 
ful /soon  again  forced  out  of  consciousness,  no  one  can  call  this  morbid. 
In  insanity,  however,  such  dispositions,  such  thoughts,  are  persistent; 
they,  owing  to  the  duration  and  strength  of  the  cerebral  affection,  be- 
come persistently  and  deeply  impressed  upon  the  mind. 

§  38.  In  order  to  a  correct  understanding  of  insanity,  we  must  our- 
selves endeavor  to  tliink  with  the  insane.  From  the  mental  states  which 
are  sdll  within  the  limits  of  health,  and  therefore  within  our  own  expe- 
rience, Ave  may  form  some  conception  of  what  takes  place  within  the  dis- 
eased mind.  Tlie  phenomena  of  dreaming,  the  state  of  the  emotions, 
mental  fatigue,  etc. — especially,  however,  the  above-mentioned  moderate 
changes  of  disposition  which  in  health  arise  spontaneously  out  of  slight 
physical  disorders — are  for  this  purpose  especially  instructive.  For,  ob- 
servation shows  that  these  phenomena,  on  the  one  hand,  of  anger,  of 
inclination  to  rage,  of  discontent,  rancour,  and,  on  the  other,  of  joy, 
gaiety,  frolic,  are  frequently,  and  with  unwonted  persistence  and  inten- 
sity, found  to  be  marked  elementary  phenomena  of  insanity;  conse- 
quently, many  of  the  conditions  of  healthy  life  are  met  with  in  insanity, 
and  are  by  the  comparison  considerably  elucidated. 

But  we  find  other  psychological  anomalies  in  the  insane  to  which 
there  is  nothing  analogous  in  the  state  of  health,  and  for  this  reason  we 
are  unable  fully  to  comprehend  them.  Thus,  we  cannot  form  any  clear 
conception  of  what  is  meant  when  we  hear  insane  persons  complain  that 
their  thoughts  are  entirely  made  for  them  by  others,  or  that  they  are  ab- 
stracted from  them,  or  when  we  see  how,  with  particular  words  and 
gestures,  they  associate  some  very  mysterious  sense,  and  attribute  a  secret 
importance  to  them.  The  deepest  mental  fatigue  cannot  even  afford  any 
analogy  approaching  the  destruction  of  thought  occurring  in  dementia; 
scarcely  even  can  the  peculiar  states  of  sleep  and  dreaming  convey  any 


THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE,  4:5 

* 

adequate  idea  of  it.     Whoever  has  experienced  the  delirium  of  fever  may, 
therefore,  form  some  notion  of  wliat  takes  place  in  mental  disease. 

In  the  following  paragraphs,  in  speaking  of  the  individual  morbid  states  of 
disposition,  thought,  and  effort,  we  will  always  refer  to  the  corresponding  physi- 
ological states.  This  threefold  division  of  mental  disturbances  is  merely  conven- 
tional to  render  their  study  more  simple;  their  more  intimate  relations  will  be 
understood  from  paragraphs  25-34. 

A.  Anomalies  of  Sentiment. 

§  39.  Observation  shows  that  the  great  majority  of  mental  diseases 
are  first  manifested,  not  by  senseless  discourse  or  extreme  acts,  but  by 
morbid  changes  of  disposition,  anomalies  of  the  self-sensation  and  the 
sentiments,  and  consequent  emotional  states.  And,  indeed,  the  earliest 
stages  of  insanity  generally  consist  in  an  aimless  feeling  of  ill-humor, 
discomfort,  oppression,  and  anxiety,  owing  to  the  fact  that  the  new 
groups  of  ideas  and  instincts  resulting  from  the  cerebral  affection  are 
usually  at  first  exceedingly  obscure.  On  this  account,  the  disturbance 
of  the  normal  process  of  thought  and  will,  and  the  new  mental  states 
obtruding  on  the  /,  are  first  felt  simply  as  vague  modifications  of  the 
sentiment  and  disposition.  The  diminished  power  and  energy  of  the  /, 
the  contraction  of  its  sphere  of  ideas,  produces  an  indefinite  state  of 
mental  pain,  and,  from  its  vagueness,  great  irritation  of  the  feelings. 
The  new  morbid  perceptions  and  instincts  produce  divisions  of  the  mind, 
a  feeling  of  division  of  the  personality,  and  of  imminent  annihilation  of 
tlie  /.  The  mental  pain  discovers  itself  in  some  of  the  familiar  forms  of 
agitation,  anxiety,  sadness,  and  entails  all  of  the  forementioned  (§  21) 
consequences  of  a  radically  changed  reaction  towards  the  external  world, 
and  of  a  disturbance  in  the  motory  function  of  the  mind.  Perversions 
of  the  natural  feelings,  aversion  and  hate  towards  those  formerly  loved, 
outward  insensibility,  or  a  morbid  fondness  clinging  to  a  single  object, 
but  without  the  depth  and  tenderness  of  the  normal  sensation,  and  sub- 
ject to  rapid  and  capricious  changes,  are  here  ordinary  appearances. 
The  increased  sensibility  involves  everything,  because,  indeed,  it  is 
painfully  affected  by  everytiiing,  and,  from  the  mournful  complexion 
that  pervades  all  his  views  and  opinions,  the  individual  puts  an 
evil  interpretation  upon  everything  present,  and  discovers  in  the  future 
nothing  but  evil.  Distrust  and  susi)icion  are  engendered  by  the  feeling 
of  diminished  power  of  resistance,  and  are  constantly  excited  by  bodily 
feelings  of  anxiety.  Everything  appears  strange  to  him,  because  he  acts 
strangely  towards  every  mental  impression,  because  he  himself  feels  al- 
tered, and  he  feels  a  strong  inclination  to  ascribe  his  condition  sometimes 
to  the  direct  influence  of  the  outer  world — to  believe  that  he  is  ])ursued, 
influenced,  charmed,  governed  by  secret  influences — and  at  others  to 
refer  to  his  former  life  for  the  causes,  and  to  accuse  himself  of  a  variety 
of  serious  crimes,  depravities,  and  misdeeds,  of  which  his  present  posi- 
tion is  the  necessary  consequence. 

Here  the  most  varied  modifications  of  those  fundamental  states  are  to  be  ob- 
served; sometimes  an  entire  absorption  of  the  individual  in  self,  sometimes  total 
despair,  frequently  malevolence;  occasionally  sympathetic  tenderness,  persistent 
self-torture;  sometimes  continual  dissatisfaction  with  the  external  world;  some- 
times weariness  of  life  and  calm  determination  to  commit  suicide;  sometimes 
dread  of  death,  of  the  pains  of  hell,  etc.  Frequently  the  patient  is  conscious  of 
the  commencement  of  insanity,  occasionally  he  seeks  advice,  and  we  have  known 
patients  in  the  preliminary  stages  voluntarily  conaing  from  great  distances  to  the 
asylum. 


46  THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE. 

The  above-named  states  are  the  foundation  of  the  various  forms  of  melancholy, 
although  they  present  themselves  also  in  other  forms  (as  in  chronic  mania).  In 
the  majority  of  cases  the  patients  feel  great  disquiet,  even  misfortune,  which  may 
probably  have  originated  the  old  appellation  of  ?/iorosita^es  applied  to  all  who  were 
mentally  diseased.  The  analogues  in  healthy  life  corresponding  to  these  states 
are,  all  depressed  dispositions  and  emotions,  discouragement,  immoderate  irrita- 
bility— habitually  bitter,  discontented,  and  self-vexatious  frames  of  mind — as  are 
occasionally  observed  in  highly  intellectual  minds  (J.  J.  Rousseau);  groundless 
jealousy,  anger,  fear,  irritability,  etc. 

§  40.  The  morbid  states  of  emotion  with  a  disposition  to  gaiety,  cheer- 
fulness, frolic,  with  increased  mental  and  bodily  activity,  are  closely 
analogous  to  the  expansive  emotions,  and  they  are  both  followed  by  es- 
sentially the  same  immediate  consequences.  There  is,  even  in  health,  a 
possibility  of  being  ''joy-mad;"  a  state  in  which,  not  only  the  feeling  of 
present  happiness  expands  all  the  powers  of  the  soul,  but  the  dreams  of 
the  future  seem  to  be  realized,  and  in  which  men  and  things  come  nearer 
to  us — in  which  we  could  allow  every  man  to  share  our  fortune,  and 
could,  as  it  were,  embrace  the  world.  Even  in  these  states  it  can  attain 
to  a  certain  degree  of  disorder  and  incoherence  of  the  ideas,  and  it  always 
shows  that  the  excitation  is  not  deep  when  the  fortunate  one  can  quickly 
regain  all  his  faculties.  Also  in  health  there  is  usually  combined  with 
these  feelings  an  impulse  to  external  movement,  restlessness,  talkative- 
ness, and  business.  These  states  are  similarly  exhibited  when  they  origi- 
iiate  morbidly,  from  within  outwards;  they  generally  form  the  fundamen- 
tal states  of  monomania,  and  are  present,  although  in  a  much  weaker 
degree,  in  chronic  mania  and  dementia.  In  accordance  with  what  we 
have  ourselves  observed,  we  must  coincide  with  the  view  of  Guislain,  that 
joyous  insanity  almost  invariably  makes  its  first  appearance  as  succeeding 
states  of  depression  that  have  passed  off.  On  this  account  it  seems  also 
to  depend  upon  a  mental  disease  more  deeply  seated  than  the  latter-men- 
tioned state.  It  seems  often  as  if,  upon  a  change  in  the  state  of  the 
brain,  the  previous  oppression  weighing  upon  the  soul  were  suddenly  re- 
moved, and  as  if,  as  a  symptom  of  still  deeper  destruction,  the  feeling  of 
great  mental  freedom,  the  happy  hopeful  disposition  could  arise.  A  re- 
mote analogy  taken  from  the  sensito-motory  nervous  system  presents 
itself  in  the  fact  (Purkinje)  that  when  the  extremities  are  weighed  down 
for  some  time  by  attached  weights,  immediately  after  their  removal  there 
is  experienced  an  unusual  sense  of  lightness  of  movement. 

Besides,  there  are  presented  a  number  of  other  morbid  dispositions  and  emo- 
tions, odd  capriciousness,  inclinations,  and  aversions,  sensuous  and  ideal  love, 
coquetry,  etc. ,  too  numerous  to  be  individually  stated. 

With  the  appearance  of  these  various  anomalies  of  sentiment,  commonly, 
the  relation  of  the  individual  to  the  outer  world,  his  whole  character,  his  desires 
and  tastes,  are  totally  changed.  The  amiable  man  becomes  fierce,  the  parsimo- 
nious prodigal,  the  moral  licentious,  the  modest  proud  and  insolent.  The 
changes  of  the  character  are  generally  the  most  striking  symptoms  in  the  early 
stages  of  Insanity ;  and  generally  the  insanity  itself,  in  these  cases  of  slow 
gradual  origin,  appears  simply  as  an  excessive  development  of  the  natural  dis- 
position or  peculiarity  of  the  individual.  Therefore,  frona  the  peculiarities  in 
the  sentiments  of  the  patient,  it  is  only  with  the  greatest  caution  that  we  should 
venture  to  express  on  opinion  as  to  his  former  character.  Extreme  viciousness 
and  malevolence  can,  for  example,  during  the  duration  of  the  malady,  con- 
tinue for  years  in  men  of  at  other  times  kind  and  benevolent  natures,  and  on 
recovery  the  old  dispositions  may  be  quickly  revived,  and  no  trace  left  of  the  dis- 
ease. 

§  41.  The  anomalies  of  emotion  which  have  been  hitherto  described 
are  to  be  regarded  essentially  as  appearances  of  abnormal  emotional  irri- 


THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE.  47 

tability.  There  are  also,  however,  abnormal  states  of  dulness,  and  even 
of  total  loss  of  emotion.  Here  either  the  occasional  perceptions  are  no 
longer  connected  with  the  changes  in  the  relation  of  tension  of  the  quiet 
masses  of  perceptions  of  the  /  which  occur  in  the  healthy  state — there  is 
little  or  no  disturbance  of  the  emotions  generally — or  it  may  be  that 
these  events  occur  indeed,  but  they  are  no  longer  known  to  the  indi- 
yidual,  and  therefore  have  no  existence  to  him.  To  all  that  formerly 
interested  him  he  is  now  equally  indifferent,  and  he  is  no  longer  capable 
of  being  much  affected  by  any  new  sentiment;  participation  and  interest, 
pain  and  pleasure,  love  and  hate,  cease.  Apathy  and  indifference  to 
everything  beyond  the  satisfaction  of  his  sensuous  requirements  succeed. 
Intelligence  can  thereby  be  tolerably  maintained,  but  generally  a  greater 
or  less  degree  of  dementia  is  apparent. 

Perversion  of  the  affections  is  a  state  of  considerable  importance  in  a  medico- 
legal point  of  view,  and  one  which  is  frequently  difficult  to  distinguish.  It 
appears  as  a  morbid  state  acquired  principally  by  onanists  and  drunkards,  and  is 
recognized  to  be  a  disease,  especially  where  it  originates  rapidly.  It  forms  an 
essential  clement  in  veiy  many  states  of  chronic  mania  (see  Book  III.),  where 
commonly  all  interests  are  extinguished  excepting  such  as  relate  to  certain  insane 
ideas  and  to  the  individual  himself  ;  indeed,  there  are  cases  where  the  perversion 
of  the  affections  and  the  apathy  appear  as  the  chief  elements.  In  a  remarkable 
medico-legal  case  which  was  decided  by  the  opinion  of  the  author  (Seitz),  the 
crime — the  murder  of  three  of  his  own  children— proceeded  directly  from  this 
anomalous  state  of  the  affections.  And,  indeed,  in  crimes  of  this  kind,  where  the 
patients  are  quite  rational,  the  physician  cannot  be  too  careful  to  discover  condi- 
tions of  this  nature. 

B.  Anomalies  of  Thought. 

§  43.  Within  the  sphere  of  distinct  perception,  of  opinion,  and  con- 
clusion, we  can  readily  distinguish  two  varieties  of  abnormal  states. 
First,  there  is  an  abnormal  relation  of  perception  in  the  abstract;  sec- 
ondly, abnormal  views  in  relation  to  its  (false)  objects.  These  states  are 
intimately  related,  inasmuch  as  certain  formal  modifications,  for  example, 
too  rapid  succession  of  the  ideas,  extreme  slowness  in  the  course  of 
thought,  or  disorder  of  the  feelings  which  necessarily  accompany  them, 
excite  or  promote  certain  morbid  ideas;  for  example,  the  moderate 
excitation  of  perception,  where  the  combinations  proceed  with  increased 
facility,  is  frequently  accompanied  by  false  judgments,  which  result  from 
the  feeling  of  mental  liberty  and  mental  well-being. 

a.  Formal  Deviations. 

Extreme  sluggishness  of  thought  depends  either  on  suppression  aris- 
ing from  violent  mental  pain,  which  entirely  occupies  the  mind  and  per- 
mits nothing  else  to  approach  it,  or  on  real  weakness,  especially  loss  of 
memory.  In  both  cases,  however  different  they  may  be  as  to  their 
internal  causes,  there  is  observed  poverty  and  sameness  of  thought,  the 
train  of  thought  appears  to  stand  still;  single  words,  modes  of  expression, 
movements,  repeated  for  hours,  show  the  continued  presence  of  the  same 
perceptions.  _  There  is  often  observed  a  hesitation  of  the  speech,  great 
uncertainty  in  the  connection  of  the  thoughts,  and  timidity  in  judging. 
This  condition  is  found  principally  in  melancholia  and  in  dementia. 

This  insufficient  interchange  of  the  perceptions  is  a  very  important  element 
in  many  mental  diseases.  The  patient  can  no  more  thoroughly  divest  himself  of 
certain  perceptions,  he  is  no  longer  free,  he  is  continually  exposed  to  their  tor- 
menting influences  and  impulses;  he  feels  how,  gradually,  in  spite  of  his  opposi- 
tion, his  I,  the  oneness  of  his  person,  is  being  snatched  from  him.     Similar  states 


48  THE    ELEMENTARY    DI80KDERS    IN    MENTAL    DISEASE. 

may  be  observed  even  in  dreaming;  many  repugnant  ideas  by  their  constant 
recurrence  induce  a  state  of  despondency.  As  will  be  found  on  minute  consid- 
eration, sleeplessness  often  arises  from  the  continued  influence  of  a  group  of 
ideas;  whenever  these  disperse  sleep  returns. 

An  increased  joroduction  and  accelerated  flow  of  the  thoughts  in  some 
degree  facilitates  mental  combinations;  therefore  we  sometimes  observe 
individuals  who  at  other  times  are  even  intellectually  dull  become  acute 
and  witty,  especially  in  the  happy  expression  of  raillery  against  indi- 
viduals present,  versification,  etc.  On  that  account  we  hear  little 
wisdom  from  the  insane.  Then,  even  in  these  states  where  abundant 
material  is  offered  to  the  cultivated  imagination,  generally  disorder  and 
incoherence  very  soon  appear.  Particularly  wlien  great  numbers  of  per- 
ceptions originate  in  the  brain,  and  their  course  is  accelerated,  are  they 
succeeded  by  long  series  of  ideas;  and  frequently  long-forgotten  images 
and  events,  words,  songs,  and  so  forth,  are  renewed  with  the  freshness  of 
first  impressions;  but,  inasmuch  as  the  perceptions  so  rapidly  succeed 
each  other,  that  tliey  cannot  enter  into  the  necessary  combinations,  and 
inasmuch  as  the  multiplicity  of  thoughts  is  attended  by  corresponding 
changes  in  the  sentiments,  the  only  result  is  extreme  agitation  and 
tumult  of  ideas.  All  is  hurried  along  in  the  most  confused  succession, 
and  it  is  a  chance  if  here  and  there  in  this  turmoil  tlie  elements  of  a. 
quaint  idea  meet  together  which  is  in  the  least  more  rational  than  what 
surrounds  it. 

The  latter  states  appear  principally  in  mania.  There  is  often  appar- 
ently great  mental  vivacity,  especially  at  their  commencement,  and  we 
have  known  cases  where  it  was  the  invariable  symptom  of  an  approaching 
attack  when  the  patient  became  witty. 

Incoherence  of  the  ideas  does  not,  however,  solely  originate  in  this  way, 
namely,  through  over-fulness  of  the  consciousness.  There  is  also  incoherence 
of  thought  anil  speech  corresponding  to  projections  of  the  thoughts  and  of  the 
emotions,  as  anger,  and  still  another  which  proceeds  from  complete  abolition  and 
deep  destruction  of  the  mental  processes.  The  psychological  mechanism  of  this 
last  condition  is  still  very  obscure  in  its  details,  it  appears  that  the  incoherence 
frequently  depends  on  the  fact  that  the  perceptions  are  called  forth,  not  only 
according  to  their  (similar  or  contrasting)  contents,  but  especially  according  to 
external  similarity  of  sound  in  the  words.  Perhaps  deficient  reciprocal  action  of 
the  two  halves  of  the  brain  may  have  some  influence  in  producing  incoherence. 
Incoherence  is  frequent  at  the  commencement  of  mental  diseases,  where  there  ia 
violent  disturbance  of  the  emotions,  and  here  it  is  no  more  an  evil  indication  than 
it  is  in  the  delirium  of  fever  cr  in  dreams.  On  the  otlier  hand,  tlie  incoherence 
which  first  appears  after  a  long  continuance  of  melancholia  and  mania,  or  at  the 
commencement  of  chronic  insanity,  is  significant  of  a  transition  to  the  incurable 
forms  of  dementia. 

Two  marked  examples  of  temporary  incoherence  from  transient  disturbance  of 
the  brain  in  otherwise  healthy  persons,  with  a  clear  description  of  the  progress 
of  the  symptoms,  by  Spalding  and  Gadike,  maybe  seen  in  Jessen,  "Versuch 
einer  wissenschaftlichen  Begriindung,"  etc.,  1855,  p.  180. 

To  the  morbid  states  of  tli ought  described  in  this  paragraph  there  are  found 
many  psychological  analogies,  partly  in  the  determined  persistence  with  which 
disagreeable  ideas  often  follow  us,  in  intimidation  of  the  judgment  by  an  adverse 
occurrence,  also  in  so-called  sulkiness  and  in  confusion  of  the  ideas  owing  to 
fright.  To  the  second  series  in  loquaciousness  without  ideas,  in  the  internal  con- 
fusion which  originates  from  abundant  simultaneous  reception  of  ideas  which 
have  no  common  characteristic  or  leading  direction,  or  in  the  incoherence  of 
images  in  dreams. 


*&"- 


§  43.  Memory  in  particular  is  very  variously  affected  in  mental  dis- 
ease. Sometimes  it  is  unimpaired  as  regards  the  events  of  the  former 
life  as  well  as  the  occurrences  during  the  disease.     In  the  preceding 


THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE.  49 

paragraph  we  have  spoken  of  its  morbid  increase.  It  is  more  frequent, 
however,  to  observe  enfeeblement  of  the  memory  in  various  modes. 
Dementia  in  particular  is  characterized  by  feebleness  of  sucli  a  kind  that 
events  happening  at  the  present  time  are  quickly,  even  instantaneously, 
forgotten,  Avhile  there  is  distinct  recollection  of  events  that  took  place  in 
former  periods  of  life,  which  may  even  be  the  subject  of  tolerably  well- 
ordered  conversation.  At  other  times  the  contents  of  the  previous  life 
are  either  (seldom)  completely  effaced  from  the  tablets  of  the  memory,  or 
(more  frequently)  are  so  far  removed  that  they  become  so  vague  and  so 
strange  to  the  individual,  that  they  can  scarely  be  recognized  as  events  in 
his  own  histoi'y.  Here  the  actual  individual  existence  is  dated  from  the 
commencement  of  the  disease,  and  the  entire  former  life  is  either  attrib- 
uted to  a  strange  personality  or  at  least  to  a  former  quite  different  state, 
to  an  imaginary  life.  This  estrangement,  this  complete  falling  away  of 
the  former  /,  depends,  not  only  upon  weakness  of  memory,  but  ordi- 
narily it  is  produced  and  rendered  persistent  by  special  sensitive  anoma- 
lies; but  the  disappearance  of  whole  masses  of  former  perceptions  is 
especially  favorable  to  the  consequent  internal  production  of  such  a 
delirium.' 

An  individual  who  has  recovered  from  insanity  generally  remembers 
what  occurred  to  him  during  his  disease,  and  can  often  narrate  with  re- 
markable truth  and  precision  the  most  trifling  incidents  in  the  outer 
world  and  the  minute  details  of  his  motives  and  sentiments  during  the 
disease.  He  can  often  interpret  every  glance,  word,  and  change  of 
expression  of  his  visitor — circumstances  which  suggest  an  incidental 
caution  to  those  who  have  to  do  with  the  insane,  to  be  constantly  on 
their  guard  as  to  how  they  conduct  themselves,  to  be  just  and  mild,  if 
indeed  such  an  exhortation  be  required!  This  kind  of  intelligence  is 
especially  observable  in  those  who  have  recovered  from  melancholia  and 
moderate  states  of  mania,  less  frequently  after  monomania,  of  which  the 
patient  generally  retains  very  confused  ideas.  The  statement  of  one  who 
has  recovered,  that  he  has  no  knowledge  of  anything  that  occurred 
during  his  disease,  is  to  be  received  with  caution,  since  the  patient  often 
conceals  what  he  clearly  remembers  through  deceit. 

With  the  anomalies  of  form  wliich  have  been  described  there  are  frequently 
connected  changes  in  speech  and  the  modes  of  expression.  Many  are  dumb 
owing  to  a  cessation  of  perception,  or  even  where  numerous  perceptions  are 
present,  because  no  reflex  action  occurs  in  the  apparatus  of  speech.  Others  speak 
incessantly,  their  narratives  are  endless,  or,  without  communicating  anything 
precise  to  a  listener,  the  continuous  reiiex  action  in  the  organs  of  speech  pro- 
ceeds as  incessant  prattle  (logomania  proper,  generally  with  incoherence).  Fre- 
quently it  is  rather  the  formation  of  sentences  and  the  mode  of  expression  that  is 
altered;  they  are  more  fluent  or  interrupted,  disconnected,  affected,  etc.  In 
other  cases,  which  are  the  most  interesting,  there  appear  in  the  language  of  the 
insane  newly  formed  words,  and  old  ones  are  employed  with  new  significations; 
in  short,  the  patient  forms  for  himself  a  new  language.  It  would  appear  that 
occasionally  ordinary  language  is  not  sufficient  to  express  completely  new  and 
strange  contents  of  sensation  and  perception,  and  therefore  new  words  are 
formed,  or  that  in  the  abnormal  cerebral  state  the  conventional  images  of  sound 
(words)  directly  stir  up  and  allude  to  other  perceptions  (see  §  17),  or  that  fre- 
quently the  hallucinations  of  hearing  immediately  necessitate  the  formation  of 
new  combinations  of  syllables,  which  are  then  retained  and  held  fast  (in  dream- 
ing also  there  is  thus  formed  new  words).  All  these  changes  appear  most  highly 
developed  in  chronic  mania,  more  transiently  in  mania. 

The  altered  modes  of  expression,  under  certain  conditions,  present  to  the 
practised  physician  direct  points  of  diagnosis;   those  who  feign  insanity  imitate 

'  Examples  are  found  in  g  49  and  in  "  Dementia." 


50  THE    ELEMEKTAKy    DISOKDERS    IN    MENTAI.    J)ISEASE. 

tliese  states  very  clumsily.  See  Snell,  'Zeitschrift  fiir  Psychiatrie,'  1853,  ix.,  p. 
11;  W.  Nasse,  ibid.,  1853,  x.,  p.  525;  Martini,  ibid..  1856,  xiii.,  p.  605;^  Brosius, 
ibid.,  1857,  xiv.,  p.  37:  Blandet,  "Du  Delire  phonetique,"  '  Gazette  Med.,'  1845, 
No.  27. 

Z».   Perversions  of  Thought — Delirious  Ideas. 

§  44.  Mental  disease  does  not  necessarily  imply  the  existence  of 
delirious  perceptions.  Marked  changes  in  the  character  and  in  the 
sentiments,  morbid  dispositions  and  emotions,  blunting  of  the  senti- 
ments, total  or  partial  relaxation  of  the  mental  powers,  can  exist  without 
truly  insane  ideas,  as  acute  and  chronic  morbid  states  of  the  mind.  A  num- 
ber of  such  cases  may  be  comprehended  under  the  class  of  moral  insanity 
( Gemiithsioahnsinn).  But  experience  teaches  that,  in  the  great  majority 
of  cases,  the  mental  derangement  does  not  cease  here,  that  special  insane 
ideas  are  developed,  and  that  these  false  opinions  which  can  no  longer  be 
regulated  are  accompanied  by  true  delirium,  the  mental  affection,  wliich 
at  the  commencement  was  only  an  insanity  of  the  feelings  and  emotions, 
becomes  also  insanity  of  the  intellect.  The  pressure  of  _  the  morbid  un- 
easiness tends  rapidly  to  incorrect  percei)tion  and  interpretation  of 
objective  relations,  but,  at  first,  only  of  such  as  relate  to  the  patient 
himself  or  to  his  immediate  surroundings.  The  false  contents  of  the 
thoughts,  i.  e., which  are  not  in  harmony  with  the  external  world  and 
with  the  events  of  the  former  life,  at  first  generally  happen  in  such  a 
way  that  the  patient  attempts  to  account  for  his  dispositions  and  morbid 
emotions  by  the  law  of  causality  (§  23,  39).  The  most  varied  external 
causes  and  events,  and  the  innumerable  recollections  of  his  individual 
existence,  afford  abundant  material  for  this  attempt  at  explanation,  and 
circumstances,  education,  and  the  views  of  life,  have  here  the  most 
decided  influence.  For  example,  the  same  disposition  which  excites  in 
the  superstitious  mmd  the  idea  of  witchcraft  may  in  another  suggest  the 
idea  of  being  pursued  by  freemasons,  of  invasion  through  secret  magnetic 
influences,  etc.  All  hallucinations  have  a  special  influence,  as  well  on 
the  formation  of  such  insane  ideas  as  on  their  special  objects;  they  are 
so  frequent,  present  materials  for  explanation  so  lively,  obtrusive,  and 
often  so  constant,  that  in  our  experience  we  must  find  them  to  be  a 
common  source  of  insane  ideas;  thus,  the  subject  of  an  hallucination  of 
sight  who  sees  fiery  appearances  believes  himself  in  hell,  another  with  an 
hallucination  of  smell  thinks  he  is  surrounded  on  all  sides  by  dead 
bodies,  the  effluvia  of  which  he  believes  he  smells,  and  thereon  founds 
further  conclusions,  etc. 

As  to  their  contents,  two  leading  differences  are  particularly  to  be 
©beerved  in  insane  conceptions — first,  joyous,  sublime,  brilliant  ideas; 
secondly,  sombre,  sad,  and  painful  thoughts.  The  former  arise  from  the 
expansive  emotions  and  from  cheerful  joyous  hallucinations,  the  latter 
from  depressed  states  of  the  disposition,  and  gloomy  ill-boding  hallucina- 
tions, as  language  of  abuse  and  mockery  which  the  patient  is  always 
hearing,  diabolical  grimaces  which  he  sees,  etc. 

The  false  ideas  and  conclusions,  which  are  attempts  at  explanation 
and  vindications  of  the  actual  disposition  in  its  effects,  are  spontaneously 
developed  in  the  diseased  mind  according  to  the  law  of  causality;  on  the 
part  of  the  individual  the  explanations  do  not  imply  reflection,  still  less 
are  such  conclusions  formed  by  the  tedious  form  of  syllogism.  _  At  first, 
the  delirious  conceptions  are  fleeting;  the  /  perceives  them,  it  may  be 
terrified    by  them,  acknowledge  their   absurdity,   and  yet   feel   quite 


THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE.  51 

unable  to  rid  itself  of  them,  and  struggles  with  them;  gradually,  by  con- 
tinued repetition,  they  gain  more  body  and  form,  repel  opposing  ideas, 
and  form  connections  with  similar  masses  of  perceptions  of  the  /;  then 
they  become  constituent  parts  of  it,  and  the  patient  cannot  divest  him- 
self of  them,  or  only  in  some  degree  by  exchange  with  similar  false 
perceptions.  The  excited,  lively,  and  happy  insane  ideas  are  naturally, 
received  by  the  /  much  more  easily  and  completely;  it  yields  to  them 
after  a  short  resistance,  and  then  it  occasionally  gives  itself  over  to  the 
insane  perceptions,  half-conscious  imagination  in  a  world  of  happy 
dreams  arises. 

All  false  ideas,  however,  are  not  to  be  considered  as  thus  explicable; 
many  originate  with  the  fortuitous  abruptness  of  hallucinations,  or  of 
those  peculiar  quaint  thoughts  which  often  spontaneously  intrude  on 
the  healthy  mind  during  its  most  earnest  employment.  They  often 
originate  simply  from  phantasms  of  sense,  dreams,  owing  to  ex- 
ternal circumstances;  their  persistence  depends  on  the  present  dispo- 
sition of  the  patient,  and  whether  in  the  present  perceptions  any 
material  for  connection  is  found.  We  will  find,  on  careful  attention, 
that  many  such  ideas  in  the  insane  are  related  to  hallucinations,  which, 
however,  do  not  clearly  show  themselves. 

In  the  early  stages  of  insanity,  when  the  disorder  of  the  emotions  is  still  the 
principal  element,  innumerable  strange  perceptions  begin  to  pass  through  the 
mind  of  the  patient;  interweaving  themselves  with  the  ordinary  circle  of  his 
thoughts,  he  can  neither  free  himself  of  tliem  nor  assimilate  them.  At  first 
fleeting  and  changeable,  they  gradually  gain  body  and  form,  but  still  the  emo- 
tional excitement  is  the  foundation  on  which  they  stand  or  fall.  The  disturbance 
of  the  emotions  gradually  diminishes,  and  therewith  do  certain  leading  insane 
perceptions  become  proportionately  fast  rooted ;  gradually  the  entire  mental  life 
circles  round  them  and  assumes  their  character,  that  is,  the  incoherence  becomes 
systematic.  This,  too,  is  still  a  period  of  mental  activity;  the  transformation  of 
the  whole  internal  life  still  proceeds,  partly  with  the  actual  consent  of  the  I,  with 
the  co-operation  of  reason.  When  this  process,  which  is  always  slow,  is  at  last 
completed,  then  the  stationary  period  follows,  in  which  the  insane  ideas,  now 
become  fixed,  exist  merely  as  remains  of  former  active  processes. 

We  should  speak  of  fixed  ideas  only  where  the  false  opinions  have  become 
radically  and  permanently  fixed,  as  in  chronic  insanity.  In  melancholia,  mania, 
and  monomania,  they  frequently  change.  All  the  false  opinions  of  the  insane 
have  tlie  characteristic  that  they  are  related  to  the  subject  itself,  or  at  least  have 
been  formed  out  of  false  ideas  relating  to  him;  they  are  thereby  distinguished  in 
a  great  degree,  if  not  fully,  from  the  errors  of  the  healthy  mind  in  reference  to 
objective  relations.  Thus,  an  insane  man  may  believe  that  all  Jews  are  damned, 
but  merely  because  he  considers  himself  injui-ed  by  them  or  because  he  has  dic- 
tated this  punishment;  he  may  believe  in  the  existence  of  a  bridge  from  the 
earth  to  the  moon,  but  only  that  he  himself  might  walk  upon  it,  or  that  its  con- 
fitruction  may  afford  a  proof  of  his  creative  power.  Nearly  all  fixed  ideas  are, 
when  reduced  to  their  fundamental  elements,  expressions  of  a  frustration  or 
gratification  of  what  specially  relates  to  the  emotions,  therefore  their  separate 
consideration,  as  if  they  were  the  chief  points  in  insanity,  always  tends  to  a  one- 
sided and  narrow  view,  and  the  knowledge,  as  well  as  the  medical  treatment  of 
them,  can,  in  individual  cases,  rest  only  upon  the  view  of  the  mental  states  lying 
at  their  foundation. 

The  insane  ideas  of  the  mentally  diseased  are  distinguished  from  the  erroneous 
'  views  of  the  healthy,  not  only  by  the  circumstance  of  their  relation  to  the 
diseased  subject  himself,  but  also  by  numerous  other  essential  characteristics. 
They  are  always  connected  with  a  disturbance  of  the  whole  mental  process, 
(emotions,  incoherence,  etc.),  whether  it  be  that  they  arise  therefrom  (generally 
in  the  preliminary  stages)  or  that  they  involve  such  disturbance.  Often  they 
are  directly  opposed  to  the  former  views  held  by  the  individual;  he  cannot  get 
rid  of  them  at  will;  they  resist  "against  the  testimony  of  sense  and  under- 
standing," adjustment,  and  correction,  and  therefore  stand  in  a  quite  different 
relation  to  the  emotions  and  the  will;   they  depend  upon  a  disturbance  of  the 


52  THE    KLEMENTAKY    DISORDERS    IN    MENTAL   DISEASE. 

brain  which  frequently  shows  itself  in  other  morbid  nervous  symptoms  (disorder 
of  the  sleep,  hallucinations,  paralytic  appearances,  etc.).  We  can  easily  see  from 
this  how  unreasonable  and  fundamentally  false  it  is  to  consider  the  errors,  "  the 
delusion"  of  by-gone  ages,  as  the  belief  in  witchcraft,  enchantments,  etc.,  as  at 
all  analogous  to  mental  disease. 

On  the  special  form  of  the  delirium,  there  is  still  another  circumstance 
which  exercises  great  influence,  and  which  hitherto  has  not  received 
sufficient  attention,  namely,  that  the  nature  of  the  delirium  is  often 
determined  by  the  series  of  perceptions  which  last  actively  engaged  the 
patient's  attention  immediately  before  the  outbreak  of  the_  insanity. 
Consequently,  if  these  are  constantly  dwelt  upon  by  the  patient,  it  is 
often  erroneously  supposed  that  they  have  been  the  cause  of  the  insanity, 
while,  on  the  contrary,  they  may  have  been  completely  or  to  a  great 
extent  fortuitous. 

In  the  year  1848,  when  all  the  world  was  engrossed  in  politics,  it  was  believed 
that  in  many  cases  politics  had  been  the  cause  of  insanity.  Flemming  ( '  Psy- 
chosen,'  p.  158)  brought  forward  two  examples  where  the  patient  had  attended 
the  hunt  shortly  before  the  outbreak  of  the  insanity,  and  the  delirious  concep- 
tions for  a  long  time  referred  to  the  incidents  of  the  hunt;  another  had  just  been 
reading  an  account  of  a  journey  to  the  Himalayas,  and  that  formed  the  central 
point  of  the  delusions.  The  same  is  observed  in  acute  delirium.  In  a  case  known 
to  me,  where  the  last  healthy  employment  of  a  typhus  patient  was  reading  the 
account  in  the  newspapers  of  the  war  then  raging  in  the  Crimea,  the  delirium 
of  the  fever  for  several  weeks  was  confined  to  the  subject  of  that  event. 

§  45.  Whether  the  patient  is  affected  by  only  a  few  or  by  very  many 
false  opinions,  whether  his  delirium  is  partial  or  general,  is  to_  be  con- 
sidered in  estimating  his  condition,  and  is  at  least  of  some  diagnostic 
value,  as  the  first  case  is  observed  more  generally  in  melancholia  and 
monomania,  the  latter  in  mania.  But  it  is  wrong  to  base  a  distinction 
of  forms  on  the  fact  of  the  insanity  being  partial  or  general.  EspeciaUy 
would  it  be  fundamentally  false  to  believe  in  the  existence  of  states  in 
which  the  patient  has  but  one  single,  limited,  fixed  idea,  while  in  all 
other  respects  his  ideas  are  quite  healthy.  We  shall  afterwards  see  that 
even  where  this  appearance  can  earliest  arise,  namely,  in  the  form  of 
chronic  insanity,  there  is  always  present  a  deep  inward  destruction  of 
the  mental  unity.  So,  then,  the  one-sidedness  of  the  delusions^ ordinarily 
depends,  not  so  much  on  the  patient's  having  only  one  fixed  idea  as  on 
the  fact  that  the  same  idea  is  constantly  repeated  by  him  in  preference 
to  any  other.  Finally,  these  relations  are  subject  to  frequent  change. 
The  same  patient,  in  the  same  form  of  insanity,  can  not  only  change  his 
ideas  from  one  day  to  another,  but  he  can  also  to-day  renounce  false 
opinions  upon  many  points,  while,  perhaps,  the  day  before  he  was  de- 
luded only  on  one  accustomed  favorite  idea. 

The  establishment  of  a  class,  monomania  (in  opposition  to  mania),  which 
related  less  to  the  existing  of  a  single  fixed  idea  than  to  the  one-sided  dominion 
of  a  particular  impulse  (monomania  of  murder,  of  theft,  etc.),  by  setting  aside 
the  most  important  relations,  namely,  the  fundamental  mental  state,  has  united 
wliatis  outwardly  distinct  and  separated  what  is  internally  united;  it  is  not, 
therefore,  to  be  approved  of. 

Originally  established  by  Esquirol,  and  always  of  more  importance  forensi- 
callv  than  pathologically,  this  doctrine,  even  in  the  land  of  its  birth,  has  fallen 
into  a  state  of  complete  neglect.  Bariod  ('  Etudes  critiques  sur  les  Monomanies,' 
Paris,  1852),  Morel,  Falret  ('  Archives  Gen.,'  1854,  Aout),  and  in  part  also  Brierre 
and  Delasiauve,  have  declared  themselves  generally  against  it;  more  recently, 
however,  the  latter  has  candidly  modified  his  views  ('Des  Pseudomonomanies, 
ou  Folies  partielles  diffuses,'  Paris,  1859).  Scarcely  any  French  psychologist  now 
maintains  it  in  its  complete  original  sense.     The  discussion  m  the  Societe  Medicr>- 


THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE.  53 

psychologique  may  be  consulted  on  this  subject:  it,  however  does  not  offer  much 
real  information. 

The  partial  delirium,  the  government  by  a  single  delusion  which  becomes  the 
centre  of  all  thought,  bears  many  analogies  to  the  exclusive  dominion  of  some 
particular  class  of  ideas  in  health,  or  to  the  tenacious  attachment  to  a  favorite 
theory  which  to  the  subject  of  it  is  an  element  of  his  very  existence,  or  to  the 
domination  of  certain  passions,  as  love,  jealousy,  pride,  desire  for  pleasure, 
avarice,  etc.  These,  in  their  higher  grades,  when  they  expel  everything  else 
from  the  mind,  are  equally  destructive  to  the  mental  life,  and  many  even  in  their 
expression,  as  in  external  distraction  resulting  from  internal  concentration, 
affectation,  pleasure  in  outward  pomp,  present  numerous  resemblances  to  the 
corresponding  forms  of  insanity. 

(\  Anomalies  of  the  Will. 

§  46.  Volition  also  presents  in  the  insane  many  serious  deviations 
from  ordinary  states  of  health,  as  well  in  those  internal  spheres  where 
distinct  perception  is  transformed  into  conscious  effort  as  in  those  where 
indistinct,  though  not  on  that  account  less  forcible,  effort  (impulse)  is 
excited  through  sensitive  impressions  and  obscure  emotions. 

In  the  first  place  stand  opposed  as  extremes  a  total  absence  of  volition 
and  with  an  increased,  even  unlimited,  power  of  will.  Weakness  of  will 
may  proceed  from  inability  to  form  conclusions,  arising  from  sluggish- 
ness of  perception  or  the  want  of  an  /sufficiently  powerful  to  determine 
volition  from  an  undefined  perception,  or  it  may  depend  on  the  influence 
of  deficient  reflex  action  on  the  perceptions.  These  states  manifest  them- 
selves in  a  hopeless  apathy,  or  in  extreme  hesitation,  irresolution,  incapa- 
city to  call  up  the  accustomed  impulses  of  the  will,  for  example,  to 
ordinary  employments,  and  are  very  frequent  in  the  first,  melancholic, 
stages  of  insanity.  On  the  other  hand,  absence  of  volition  (in  demen- 
tia) originates  from  the  absence  of  clear  perceptions  in  general ;  with 
loss  of  thought,  volition  also  ceases. 

Increase  of  will  takes  the  form  of  inordinate  desire,  a  thirst  for  action, 
a  passion  for  forming  plans,  attempts  to  realize  all  thought  in  effort, 
ruling  peculiarity,  powerful  desire  towards  certain  objects  similar  to  the 
strong  directions  of  the  will  consequent  on  the  passions.  It  shows  itself 
either  as  the  frequent  result  of  a  weakened  will,  or  it  is  really  founded  upon 
a  feeling  of  increased  bodily  and  mental  power,  very  great  vigor,  and 
morbidly  increased  feeling  of  self.  The  last  frequently  appears  in  the 
form  of  so-called  monomania. 

In  general,  however,  the  morbid  emotions  bring  along  with  them  their 
corresponding  states  of  effort,  and  these  are  the  more  clear  and  distinct, 
the  morbid  volitions  are  more  special,  in  proportion  to  the  distinctiveness 
with  which  the  insane  perceptions  have  been  formed  out  of  emotions  or 
hallucinations. 

As  the  reflex  activity  of  the  spinal  cord  may  be  morbidly  excited  Ijy 
means  of  certain  influences  (as  strychnia),  or  on  the  contrary  diminished, 
it  is  the  same  with  the  brain.  An  example  of  general  diminution  of  the 
cerebral  reflex  activity  which  is  found  in  various  acute  diseases  (very 
often  in  typhus),  and  in  nearly  the  same  form  in  many  melancholic  and 
demented  states,  and  in  the  so-called  ecstasies,  is  presented  to  us  in  the 
condition  called  stupor.  Of  partial  diminutions  there  are  numerous 
examples,  but  at  present  they  are  difficult  to  define  and  to  point  out. 
The  clearest  cases  of  increased  reflex  action  are  to  be  found  in  many  con- 
ditions of  excitement.  It  is  possible  that  such  increase  may  depend  on 
a  state  of  the  brain  in  which  the  diffusion  of  the  impression  (to  another 


54  THE    ifiLEMENTARY    DISOKDERS    IN    MENTAL    DI&EASE. 

place)  is  hindered  or  prevented.  In  the  spinal  cord  we  see  that  when 
the  transmission  of  the  central  apparatus  is  interrupted  by  a  transverse 
section,  the  reflex  acts  become  stronger  in  the  i)art  below  the  point  of 
section. 

Absence  of  will  {ahulie)  is  discussed  by  Leubuscher  in  the  '  Zeitschrift 
fiir  Psychiatric,'  iv.,  1847,  p.  562. 

§  47.  Of  all  the  morbid  desires,  the  violent  impulse  to  muscular 
activity,  to  bodily  movement,  is  particularly  to  be  noticed,  as  it  is  seen, 
especially  in  states  of  mania,  as  a  constant  necessity  to  restless  motion 
hither  and  thither,  beating  about,  screaming,  etc.,  a  state  which  fre- 
quently involves  the  injury  and  destruction  of  what  is  within  reach  of 
the  patient,  without  his  having  any  definite  purpose  in  doing  so.  The 
patient  seeks  and  finds  relief  from  his  inward  pressure  and  the  burden  of 
his  feelings  by  throwing  them  outwards  (§  25)  ;  those  states  in  which 
violent  feelings  of  anxiety  or  certain  shocking  ideas  urge  the  patients  to 
take  to  the  commission  of  certain  definite  misdeeds  come  under  the  same 
category.  This  impulse  towards  a  definite  end,  towards  some  decision 
of  his  painful  condition,  may  become  so  violent  as  to  induce  the  patient 
to  the  perpetration  of  deeds  which  in  other  states  he  would  resolutely 
shun,  owing  to  the  feeling  that  thus  alone  can  deliverance  and  rest  be 
found.  Therefore,  if  we  closely  examine,  as  we  ought,  according  to  their 
motives,  the  several  known  cases  in  which  the  insane  have  manifested 
their  disease  by  dangerous  and  lawless  acts  (murder,  suicide,  incendiar- 
ism, robbery),  we  will  thereby  discover  the  great  differences  that  exist 
between  their  respective  fundamental  causes.  We  immediately  feel  how 
unsatisfactory  it  is  to  arrange  such  cases  according  to  the  nature  of  the 
acts  committed,  or  according  to  a  special  impulse  to  murder,  incendiarism, 
suicide,  etc.,  or  to  consider  them  as  "pure  diseases  of  the  will"  (mono- 
mania in  the  sense  of  lesion  of  one  of  the  faculties  of  the  mind,  of  the  will), 
and  that  it  is  necessary  to  judge  of  them  individually  according  to  the  fun- 
damental morbid  states  of  the  mind  from  which  they  proceed.  Therefore, 
the  several  impulses  of  this  kind  recur  as  motives  sometimes  melancholic, 
sometimes  maniacal,  sometimes  partially  demented,  and  we  shall  have 
again  to  refer  to  them  in  the  special  consideration  of  these  forms  of  insan- 
ity. 

In  such  tendencies  to  devise  mischief,  to  tear  the  clothing,  to  destroy  the 
furniture,  to  conceal  things  of  value,  to  steal,  etc.,  as  also  in  many  other  strange 
actions  of  a  harmless  nature  (as  always  undressing),  the  patients  are  sometimes 
prompted  only  by  a  general  necessity  to  destruction,  in  order  to  free  themselves 
of  their  ill-humor,  to  vent  their  rage,  sometimes  by  distinct  motives,  and  only  in 
the  most  rare  cases  should  these  acts  be  considered  as  purely  automatic.  Either 
hallucinations  enjoin  them  to  such  acts  or  the  effort  by  a  violent  daring  deed  to 
procure  rest  from  internal  anxiety  or  delirious  conceptions  proper.  Zeller 
('  Bemerkungen  zu  Guislain,'  p.  490)  records  a  number  of  such  cases,  with  the 
motives  given  by  the  patients.  "One  of  our  patients  beat  out  all  the  windows 
within  his  reach  with  the  greatest  quietness  and  composure  to  procure  glass  for 
the  filling  up  of  mouse-holes,  another  that  he  might  be  able  to  coin  crown  thalers 
to  his  heart's  desire.  Another  deliberately  tore  all  his  shirts  to  pieces  in  order  to 
collect  lint  for  the  military  hospitals;  another  took  down  the  stove  to  light  his 
pipe,  and  then  leisurely  replaced  it.  Another  broke  the  chairs  into  pieces,  and, 
in  answer  to  my  question  why  he  acted  so  foolishly,  he  replied  while  quietly  pro- 
ceeding with  his  work,  and  witliout  looking  up,  '  Philosophy  must  conquer 
aesthetics.' "  Nevertheless,  in  such  cases  we  must  not  place  too  implicit  confi- 
dence in  the  patient's  account  of  his  motives;  they  are  often  extremely  reserved 
in  giving  their  real  motives;  and  many  such  cases  remind  ixs  of  the  scene  in 
Shakespeare  where  Falstaff  when  in  a  dilemma  always  answered  "  in  starched 
linen"  {in  Steijieinen)'i? 


THE    ELEMENTARV    DIS0KDEB8    IN    MENTAL    DISEASE.  55 

Whether,  and  to  what  extent,  certain  directions  of  the  will  and  im- 
pulses in  the  insane,  particularly  such  as  lead  to  criminal  acts,  are 
irresistible,  is  a  question  which  can  scarcely  ever  be  answered  with 
certainty.  Few  of  the  acts  of  the  insane  have  the  character  of  forced, 
purely  automatic  movements;  in  mania  also,  according  to  the  testimony 
of  individuals  who  have  recovered,  many  of  the  wild  desires  could  often 
be  restrained;  the  criminal  deeds  of  the  insane  are  not  generally  instinc- 
tive. The  loss  of  free  will  (or,  if  we  choose,  irresponsibility),  therefore, 
seldom  depends  on  the  fact  of  inability  to  have  abstained  from  the  act 
committed,  or  that  the  normal  conditions  of  volition  have  been  completely 
suspended.  The  causes  of  this  loss  of  free  will  chiefly  depend  on  quite  a 
different  cause,  they  depend  on  violent  excitation  of  the  emotions,  or  on 
incoherence,  on  false  reasoning  proceeding  from  delirious  conceptions, 
hallucinations,  etc.,  and  on  the  circumstances  mentioned  in  §  27. 

In  the  criminal  acts  of  the  insane  tlie  circumstances  worthy  of  minute  investi- 
gation are  whether  the  patient  manifested  a  similar  tendency  (as  to  steal)  even 
in  health,  which  is  only  now  showing  itself  when  the  power  of  the  reflection  is 
suspended,  or  whether  the  desire  first  arose  with  the  insanity,  and  disappeared 
on  recovery;  whether  it  really  proceeded  from  morbid  emotions  and  insane 
ideas.  See  Jakobi,  'On  Cleptomania,' in  Jacobi  and  Nasse's  ' Zeitschrif t,'  1837, 
1  Heft,  p.  179;  Hoffmann,  "On  Cleptomania,"  '  Giinsburg  Zeitschr.,'  1,  p.  299. 

To  the  manifestation  of  such  desire,  to  the  free  disclosure  of  tendencies  which 
are  generally  concealed,  to  certain  morbid  impulses  may  be  referred  much  of  the 
peculiarity  which  distinguishes  the  conduct  of  the  insane.  Each  has  its  analogy 
in  healthy  life,  partly  in  those  peculiar  habits  and  caprices  which  are  occasionally 
observed  as  curious  appendages  to  great  and  energetic  intellects  (which  form 
the  materials  of  many  anecdotes  relating  to  learned  men),  partly  in  the  directions 
of  the  will  and  the  modes  of  action  of  the  passions  and  emotions.  These  in  detail 
afford  materials  for  numerous  comparisons,  and  we  find  in  the  poets  who  dwell 
much  on  the  emotional  states  numerous  analogies  by  way  of  example.  Thus, 
when  the  melancholic  has  the  impulse  to  leave  his  home,  and  roam  in  the  open 
air  because  it  appears  too  confined  for  him,  and  because  he  expects  alleviation 
from  his  state  of  internal  pain  by  outward  disquiet  and  change,  so  the  same 
appears  in  cases  of  real  mental  pain,  where  the  sufferer  spends  his  life  in  the  open 
air,  or  even  in  distant  lands,  in  the  world,  in  order  to  recover  internal  calm  by 
outward  disquiet  and  restlessness.  Eichendorff  has  well  expressed  this  disposi- 
tion in  one  of  his  well-known  songs. 

Section  II. — The  Elementary  Disorders  of  8ensatio7i. 

§  48.  Previous  to  the  consideration  of  anomalies  of  sensation — so 
important  in  insanity — we  shall  consider  the  various  modes  in  which 
the  general  feeling  of  illness  is  manifested.  In  the  majority  of  cases  of 
mental  disease  this  feeling  of  illness  is  altogether  absent;  generally,  there- 
fore, the  patients  do  not  feel  ill,  and  often  protest  against  medical  treat- 
ment. Indeed,  in  not  a  few  cases  of  serious  mental  disease  there  is, 
instead  of  a  feeling  of  illness,  a  sense  of  extreme  well-being,  of  increased 
bodily  power  and  vigor.  Such  patients  (maniacs)  are  often  angry  and 
irritated  when  any  doubt  is  expressed  as  to  their  perfect  health,  and 
voluntarily  refer  to  their  excellent  appetite — morbidly  increased — to  prove 
it.  This  absence  of  the  feeling  of  illness  is  observed  in  a  number  of  brain 
affections,  sometimes  after  injuries  of  the  head,  and  very  commonly  in 
-acute  meningitis  and  the  affections  of  the  brain  in  typhus  fever.  At  the 
height  of  the  disease,  when  interrogated,  the  patient  generally  answers 
that  he  is  quite  well,  occasionally  even  he  assures  us  that  we  are  much 
deceived  by  considering  him  as  ill,  while,  when  the  danger  is  past  and 
the  symptoms  alleviated,  there  enters  a  strong  feeling  of  illness,  of  deei) 


56  THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE. 

depression  and  fatigue.     This  feeling,  then,  is  generally  present  in  con- 
valescence from  these  forms  of  insanity. 

There  are,  on  the  other  hand,  other  states  of  insanity  where  the  feel- 
ing of  illness  is  not  only  present,  but  seems,  in  relation  to  the  objective 
symptoms,  to  be  immediately  increased.  The  patient  is  thereby  deceived 
as  to  the  objective  facts  of  his  state  of  bodily  feeling  and  indulges  in  false 
ideas  of  serious  special  disease.  There  is  thus  formed  a  disproportionately 
strong  or  persistent  feeling  of  illness,  a  fundamental  element  of  the  hyi^o- 
chondriacal  state,  and  it  is  characteristic  of  these  that  they  generally  are 
not  confined  to  general  impressions  of  bodily  discomfort,  but,  as  the  atten- 
tion is  directed  to  the  individual  organs,  disagreeable  feelings  are  awakened 
in  each  of  them.  The  same  condition  of  the  nervous  centres  is  found 
in  an  acute  manner  in  the  early  stages  of  most  severe  fevers,  but  then 
there  is  no  time  for  the  attention  to  become  fixed,  and  the  feeling  of 
illness  is  soon  justified  by  severe  objective  symptoms. 

§  49.  There  are,  besides,  numerous  other  anomalies  of  the  general  sen- 
sibility. In  the  first  place,  those  extensive  modifications  of  the  sensation 
of  self  which  ordinarily  accompany  serious  aflEection  of  the  mind  (§  43], 
and  which  establish  the  idea  of  transformation  of  the  person.  The 
patients  renounce  their  former  personality,  and  consider  themselves 
sometimes  animals  (wolves,  oxen,  etc.),  sometimes  historical  individuals 
(N^apoleon).  Sometimes  the  whole  body  is  considered  dead,  or  as  not 
really  theirs,  or  as  composed  entirely  of  inanimate  substances,  as  wood, 
glass,  wax,  butter,  etc.  At  other  times  the  body  is  merely  felt  to  be  ex- 
traordinarily heavy,  or  to  have  acquired  a  very  great  circumference,  etc. 

On  the  other  hand,  these  anomalies  of  the  general  sensation  are  some- 
times local,  confined  to  certain  parts  of  the  organism.  The  patient 
supposes  that  certain  of  his  members  are  wanting,  or  that  they  are  not 
connected  to  his  body  in  the  way  they  used  to  be.  For  example,  ke 
thinks  that  he  no  longer  has  a  head,  that  one  of  his  arms  or  legs  is  petri- 
fied or  made  of  glass.  Or  he  feels  as  if  a  certain  part  were  uncommonly 
large,  and  the  nose  in  particular  is,  in  many  cases,  the  object  of  this 
illusion. 

There  are,  besides,  observed  in  the  insane,  as  more  transient  states, 
sensations  familiar  to  many  healthy  persons  in  dreaming,  of  flying  high 
in  the  air,  of  being  precipitated  from  a  height,  or  of  general  giddiness. 
Sometimes  a  veritable  aura  is  felt  before  an  attack,  as  it  is  before  an  epi- 
leptic seizure. 

The  seat  and  the  more  immediate  cause  of  these  anomalies  of  the  gen- 
eral sensation  are  difficult  to  understand.  In  several  cases,  indeed,  they 
depend — for  example,  the  feeling  of  absence  of  a  part  of  the  body — on 
evident  ana3sthesia,  or  more  frequently  an  analgesia  of  the  organ.  At 
other  times,  however,  the  peripheral  sensibility  of  the  cutaneous  surface^ 
and  perhaps  even  the  sensibility  to  pain,  is  fully  maintained,  and  obscure 
modificatians  of  the  muscular  sensibility,  Avhich  likewise  appear  to  play 
an  important  part  in  ordinary  dreaming,  may  be  the  original  disorder 
which  the  explanatory  reflection  lays  hold  of  to  form  delirious  concep- 
tions. The  transformation  into  animals  appears  to  be  much  more  related 
to  the  mind  in  its  origin,  and  the  basis  of  this  false  idea  may  depend  on 
the  appearance  and  iniiuence  of  certain  instincts  peculiar  to  certain 
species  of  animals,  as  the  cruelty  and  ferocity  of  the  wolf.  But  here  also 
a  marked  deviation  from  the  normal  general  sensation  is  always  necessary 
to  the  full  development  of  the  ideal  metamorphosis. 

Leuret  (' Fragm.  Psychol,   sur  la  Folie,'  Paris,    1834,   p.  101)  has  made  an 


THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE.  57 

interesting  collection  of  several  old  examples  of  the  so-called  Lycauthropia,  and 
several  cases  of  more  recent  date  of  insane  persons  wandering  in  the  woods  and 
carrying  off,  and  even  kilhng,  children,  frona  a  fierce  instinct  to  murder.  Wier 
narrates  an  example  of  a  man  from  Padua  who,  in  the  year  1541,  believed  him- 
self transformed  into  a  wolf,  and,  on  the  open  plain,  attacked  and  slaughtered 
those  whom  he  met.  "  I  am  really  a  wolf."  said  he,  "  and  the  reason  why  my 
skin  is  not  hairy  like  that  of  a  wolf  is  that  it  is  reversed  and  the  hairs  are  inside." 
To  convince  himself  of  this  he  made  incisions  in  his  body,  and  cut  his  legs  and 
arms,  so  that  he  died  of  the  wounds. 

Examples  of  insane  persons  considering  themselves  dead,  and  not  recognizing 
tlieir  body  as  their  own,  are  numerous.  Esquirol  mentions  that,  in  a  woman 
who  believed  that  the  devil  had  carried  away  her  body,  the  surface  of  the  skin 
was  completely  insensible.  This  was  also  the  case  in  the  following  example  from 
Foville.  A  soldier  considered  that  he  had  been  dead  since  the  battle  of  Auster- 
litz,  in  which  he  was  severely  wounded.  When  any  one  asked  how  he  was  he 
answered,  "  You  ask  how  father  Lambert  is,  but  father  Lambert  is  no  more,  he 
was  carried  off  by  a  cannon  ball  at  Austerlitz.  That  which  you  now  see  is  not 
him,  but  merely  a  clumsy  machine  made  to  resemble  him;  pray  make  another." 
When  he  spoke  of  himself  he  never  said  7,  but  always  it.  The  skin  is  insensible, 
and,  several  times,  attacks  of  various  kinds  of  immobility  and  insensibility  have 
occurred. 

A  young  epileptic,  who  had  also  numerous  hallucinations  of  smell  and  of 
taste,  sometimes  felt  his  whole  body  of  such  an  extraordinary  weight  that  lie 
could  scarcely  stand  upright,  at  other  times  of  such  lightness  that  it  seemed  as  if 
he  rose  from  the  floor  and  flew;  besides,  his  body  and  his  limbs  seemed  to  him 
so  enormously  enlarged  that  it  was  impossible  for  him  to  pass  through  a  door.' 

To  such  states  there  are  also  analogues  in  acute  diseases.  A  medical  friend 
has  frequently  told  me  that  he,  in  even  slight  febrile  affections,  has  always  the 
sensation  of  remarkable  enlargement  of  the  limbs. 

A  convalescent  from  fever  believed  that  he  was  really  two  persons,  one  of 
whom  lay  in  bed  while  the  other  walked  about.  Although  he  had  little  or  no 
appetite,"yet  he  ate  a  great  deal,  because  he  had  to  nourish  two  bodies  (Leuret, 
loc.  cit.,  p.  95). 

Patients  with  paralysis  of  sensation  of  one  half  of  the  body  have  sometimes 
the  idea  that  another  person,  or  even  a  corpse,  lies  beside  them  in  bed  (Bouilland, 
'  Traite  de  FEucephalite,'  Paris,  1825,  p.  6-1).  Such  false  opinions  belong  to  the  so- 
called  illusions,  soon  to  be  considered;  further  examples  will  be  given  in  §  61. 

The  sensation  of  flying  in  dreams  appears  to  be  due  to  acceleration  of  the 
inspiratory  movements,  and  that  of  being  drawn  from  a  height  to  their  becoming 
slower  (Gratiolet);  corresponding  images  are  associated  with  these. 

All  considerable  alterations  of  the  common  sensation  are  always  amongst  the 
most  important  elements  of  mental  disease.  When  this  general  basis  of  the 
bodily  sensations  is  falsified,  corresponding  false  ideas  are  formed  with  extreme 
facility.  These  anomalies  are  always  to  be  specially  investigated,  as  they 
occasionally  furnish  indications  for  therapeutical  treatment. 

§  50.  The  angesthesias  of  the  insane  have  to  be  considered  more  in 
detail.  Diminution  or  complete  suppression  of  tlie  sensibility  of  the 
skin  to  impressions  of  temperature  and  of  pain  is  by  no  means  frequent, 
still  less  is  it  general  in  insanity.  We  find,  on  the  contrary,  in  some 
instances  an  excess  of  sensibility  to  pain  (Esquirol  relates  such  a  case), 
and  it  is  remarked  that  in  asylums  in  winter  the  patients,  with  very  few 
exceptions,  constantly  seek  the  warmth.  Nevertheless,  cases  of  tran- 
sient and  persistent  cutaneous  anaesthesia  (as  already  shown  in  the  forego- 
ing §),  and  of  analgesia,  are  sometimes  seen,  particularly  in  states  of 
melancholia  and  dementia,  and  confined  to  more  local  limits,  is  also  fre- 
quent in  hysteria.  A  careful  investigation  of  the  cutaneous  sensibility 
in  the  various  parts  of  the  body  should  always  be  made. 

Rochoux  (Sitting  of  the  Academic  deMedecine,  22dDec.,  1840)  communicated 
a  case  of  accident  which  occurred  through  want  of  sensation  in  the  patient.  A 
patient  in  Bicetre,  while  no  one  was  in  the  room,  laid  his  head  on  the  red-hot  iron 

1  Bottex,  '  Essay  on  Hallucinations,'  Lyons,  1856,  pp.  58-61. 


58  THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE. 

of  the  Stove;  and  put  his  arm  into  the  midst  of  the  fire.  The  strong  smell  first 
drew  the  people  near;  the  patient  was  quite  unconcerned  and  throughout  gave 
no  sign  of  pain,  though  the  arm  was  burned  to  the  bone. 

In  the 'Zeitschrift  fiir  Psychiatrie,' xi..  1854,  p.  717,  there  is  an  example  of 
voluntary  self-burning  by  a  melancholic  patient.  He  was  quite  happy,  although 
legs,  thigh,  and  nates  were  burned,  so  that  even  the  bones  were  charred.  A 
patient  in  Bedlam,  mentioned  by  Morison,  laid  the  back  of  his  head  upon  the 
fire  till  the  greater  part  of  the  cerebral  coverings  were  burned;  he,  however, 
recovered.  Michea  ('Gaz.  Hebdom.,'  1856)  cites  a  number  of  cases  in  which 
melancholies  sufl:ered  mutilation  without  pain  (analgesia),  and  it  is  interesting 
that  this  state  often  exists  also  in  Delirium  traumaticum  (nervosum),  so  that  the 
patients  tear  off  the  bandages,  and  use  most  regardlessly  the  broken  limbs  (Dupuy- 
tren,  Klose). 

Snell  ('  Zeitschrift  fiir  Psychiatric,'  x.,  1853,  p.  213),  in  180  patients,  found  the 
skin  quite  angesthetic  in  18  (?),  and  in  0  there  was  analgesia;  the  anaesthesia  in 
states  of  excitation  and  depression  was  present  always  in  cases  presenting  little 
hope  of  recovery.  A  very  remarkable  case  is  communicated  by  Renaudin 
(Moreau,  'Psychologic  Morb.,'  p.  313),  of  a  boy  who  had  hitherto  conducted  him- 
self perfectly  well,  and  all  at  once  exhibited  the  worst  desires  and  most  reprehen- 
sive  behavior.  He  was  not  entirely  insane,  but  the  whole  cutaneous  surface 
became  sensationless.  This  state  was  intermittent,  and  when  it  went  off  the  patient 
became  again  quite  orderly  and  obedient.  Simultaneously  with  the  anaesthesia 
the  worst  desires,  even  desire  to  murder,  returned.  In  general  paralysis,  too, 
there  is  sometimes  present  an  evident  diminution  of  the  cutaneous  sensibility. 
Diminution  of  the  sense  of  smell  may  be  assumed  in  those  patients  who  would 
amuse  themselves  with  their  excrements.  All  these  anaesthesias  must  have  a 
central  basis. 

We  sometimes  hear  the  insane,  especially  melancholies,  complain  of 
■quite  a  different  kind  of  anaesthesia,  which  is  more  related  to  the  intellect- 
ual, most  inward,  act  in  sensation.  "I  see,  I  hear,  I  feel,"  say  they, 
"but  the  subject  does  not  reach  me;  I  cannot  receive  the  sensation;  it 
seems  to  me  as  if  there  were  a  wall  between  me  and  the  external  world," 
etc.  In  such  patients  there  is  sometimes  a  diminution  of  the  peripheral 
cutaneous  sensibility,  so  that  the  subjects  appear  to  them  somewhat 
indistinct,  as  if  rough,  woolly;  but  this,  when  constantly  present,  does 
not  explain  the  phenomenon.  These  modifications  in  the  perception  of 
sensations  rather  recall  to  us  the  changes  which,  in  general,  our  mind 
undergoes  in  regard  to  the  sensitive  world,  partly  in  the  various  ages  of 
life,  partly  in  the  emotional  and  impassioned  states.  In  the  years  of 
childhood  we  feel  the  world  of  sensitive  appearances  nearer  to  us,  we  live 
immediately  with  and  in  it,  an  intimate  bond  of  a  living  dependence 
unites  us  to  it.  As  the  reflection  becomes  matured  this  bond  becomes 
relaxed,  the  interest  cools,  things  appear  otherwise,  and  we  become 
more  strange  to  the  outer  world,  although  at  the  same  time  we  know  it 
better.  Joy  and  the  expansive  emotions  generally  draw  us  again  to 
the  external  world  ;  everything  creates  anew  a  lively  impression,  and 
under  the  ready  influence  of  sensuous  impressions'  joy  exercises  an  im- 
mediate and  reinvigorating  influence.  The  opposite  is  the  case  with 
the  painful  emotions ;  the  external  world,  animate  or  inanimate,  ap- 
pears to  have  become  suddenly  cold  and  strange  ;  it  seems  also  as  if 
the  objects  of  our  affection  no  longer  belonged  to  us,  and,  as  nothing 
can  now  excite  in  us  a  lively  impression,  we  become  estranged  to  ex- 
ternal objects,  and  more  and  more  concentrated  in  ourselves  (isolation). 
An  analogy  may  be  seen  between  these  latter  states  and  the  complaints 
of  the  melancholies,  as  their  intensity,  their  duration,  and  their  want  of 


'  ••  "Warum  doch  glanzt  um  uns  das  All 't 
Jeglichem  Staub  sein  Herz  erschlossen  !" 


THE    ELEMENT AKV    DISORDEKS    IN    MENTAL    DISEASE.  59 

mentiil  motive,  urge  the  patient  openly  to  complain  of  such  changes  in 
his  power  of  receiving  impressions. 

Further  examples  of  these  conditions  will  be  found  in  the  chapter  on  melan- 
choly. In  another  point  of  view  they  are  also  analogous  to  the  faintness  of  sen- 
soi'ial  impression  during  sleep. 

§  51.  In  Ecstasy,  together  with  much  diminished,  or  almost,  or  com- 
pletely suppressed,  external  sensations,  there  exists  a  strong  internal  con- 
centration on  certain  feelings,  circles  of  ideas,  images,  etc.,  with  great 
elevation  and  tension  of  the  entire  mental  activity.  This  state  is  mani- 
fested by  a  very  highly  emotional  expression  of  the  countenance,  in  which 
there  is  depicted  astonishment,  rapture,  pain,  according  to  the  nature  of 
the  emotions.  It  is  generally  accompanied  by  complete  loss  of  speech, 
immobility  of  the  limbs,  and  often  by  a  cataleptic  state  of  the  muscles. 
The  patients  appear  to  be  quite  absorbed  in  their  emotions,  they  generally 
refuse  nourishment,  and  particularly  does  volition  appear  to  be  entirely 
prostrate.  These  states  are  not  very  frequent;  they  sometimes  come  on 
primarily  after  a  violent  shock,  in  hysterical  insanity,  in  onanists,  also  in 
epileptics,  and,  now  and  then,  in  alternation  with  violent  attacks  of  mania. 
Fasting,  causes  of  weakness  of  any  kind,  want  of  sleep,  appear  to  favor 
their  origin.  In  the  religious  ecstasies  of  bygone  times,  of  which  we 
have  reliable  information,  these  causes  appear  also  to  have  played  an 
important  part. 

The  diminished  external  sensibility  combined  with  immobility  of  the  body, 
sometimes  even  with  abolition  of  hearing,  cause  this  condition  closely  to  resemble 
sleep;  nevertheless,  it  is  truly  a  state  of  wakefulness,  with  complete  concentra- 
tion on  certain  powerful  domineering  circles  of  ideas  or  sensations. 

§  52.  But  the  most  general  and  most  important  sensitive  anomalies  in 
states  of  mental  disease  are  the  hallucinations  and  illusions.  By  halluci- 
nations Ave  understand  subjective  sensorial  images,  which,  however,  are 
projected  outwards,  and  thereby  become,  apparently,  objects  and  reali- 
ties. By  an  illusion  is  meant  the  false  interpretation  of  an  external 
object.  It  is  an  hallucination  when  I  see  human  forms  while  in  reality 
no  man  is  near,  or  hear  a  voice  which  has  not  spoken;  it  is  an  illusion 
when  I  take  a  bright  cloud  in  the  heavens  for  a  fiery  chariot,  or  when 
I  believe  that  I  see  an  old  friend  when  a  stranger  walks  into  the  room. 
In  hallucination  there  is  no  external  objects,  it  is  a  false  sensation;  an 
illusion  is  a  false  construction,  a  transformation  of  a  j)eripheral  sensa- 
tion. 

The  motive  to  this  sensation  does  not  necessarily  require  to  exist  in 
the  external  world,  it  may  also  be  within  the  special  organism,  therefore, 
the  false  interpretations  to  which  peripheral  pains  (neuralgic,  rheumatic) 
are  subject  are  considered  illusions,  as  the  idea  of  being  pregnant,  which 
proceeds  from  unusual  abdominal  sensations,  or  that  case  mentioned  by 
Esquirol,  in  which  a  patient  had  pain  in  the  knee,  and  kept  striking  it 
with  the  fist,  calling  out,  '"Wait,  you  rascal,  you  shall  not  escape  me  !  " 

The  distinction  between  hallucinations  and  illusions  was  made  by  Esquirol. 
It  ought  to  be  maintained,  although  it  cannot  be  adhered  to  with  perfect  exact- 
ness. In  the  senses  of  taste  and  cutaneous  sensation  especially  the  distinction  is 
often  impossible.  In  the  other  senses,  too,  the  view  of  illusions  as  false  judg- 
ments is,  in  many  cases,  too  limited.  They  are,  in  the  majority  of  cases,  actual 
transformations  of  impressions  transmitted  by  the  organs  of  sense,  wlien,  for 
example,  a  portrait  on  the  wall  appears  to  roll  its  eyes  and  walk  out  of  the  frame, 
or  when  the  visage  of  an  old  woman  appears  to  be  young  and  beautiful.  Here 
internal  images  are  substituted  for  real  perceptions;  it  is  a  mixture  of  halluci- 


60  THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE. 

nation  and  real  sensorial  perception;  the  latter  becomes  thereby  transformed 
in  the  sense  of  the  dominant  ideas  and  frames  of  mind.  We  can  also  express 
the  relation  between  them  so;  the  hallucinations  are  either  quite  complete 
when  they  provide  the  entire  object,  or  they  are  incomplete  (illusions)  when 
to  a  real  external  object  other  qualities  wliich  it  does  not  possess  are  attributed 
(Gratiolet). 

The  literature  of  sensorial  deUrium  is  very  rich.  Esquirol,  several  articles  in 
'  Dictionnaire  des  Sciences  Medicales,'  and  '  Traite  de  I'Alienation.'  Bayle, 
"  Mem.  sur  les  Hallucinations,"  '  Revue  Medic.,'  January,  1835.  Miiller,  '  Ueber 
phantastische  Gesichtserscheinungen,'  Coblenz,  1826.  Lelut,  "  De  la  Folie  Sen- 
soriale,"  '  Gazette  Med.,' 1833.  Bird,  "  Thatsachliche  Bemerkungen  iiber  Sinnes- 
tituschungen,"  '  Friedreich's  Magazin,' Heft  17,  1831.  Dietz,  "Ueber  die  Quelle 
der  Sinnestauschungen,"  ibid.,  Heft  111  1832.  Leuret,  'Fragments  psycholo- 
giques,'  Paris,  1834.  Bottex,  '  Sur  les  Hallucinations,'  Lyon,  1836.  Marc,  '  Geis- 
teskrankheiten,'  ti-anslated  by  Ideler,  i.,  1843.  Hagen,  'Die  Sinnestauschungen,' 
Leipzig,  1837.  Baillarger,  in  '  Arch.  Gener.,'  1842-43.  Patterson,  'Anal.  Med. 
Psycholog.,' Mars,  1844.  Likewise  the  writings  of  Arnold,  Reil,  Haslan,  Hoff- 
bauer,  Neumann,  Friedreicli,  Jessen,  Archambault  in  Elhs's  'Traite,'  p.  180,  seqq., 
etc.,  Sinogowitz,  'Die  Geistesstorungen,'  Berlin,  1843.  Michea,  'Du  Delire  des 
Sensations,'  Paris,  1846.  Baillarger,  "  des  Hallucinations,"  '  Mem.  de  I'Acad.  de 
Med.,  tomexii.,  Paris,  1846.  Brierre,  'Des  Hallucinations,'  Paris,  1847  (2d  edi- 
tion, 1853).  Leubuscher,  '  Ueber  die  Entstehung  der  Sinnestauschungen,' 
Berlin,  1852. 

§  53.  Hallucinations  may  occur  in  all  the  senses — in  the  senses  of 
sight,  hearing,  smell,  taste,  and  cutaneous  sensibility.  In  individuals 
sometimes  this,  sometimes  that,  frequently  several,  occasionally  all,  these 
various  sensorial  functions  are  affected  at  the  same  time  ;  the  hallucina- 
tions are  real  sensations,  not  mere  fancy.  The  patient  really,  and  not 
merely  thinks  that  he  hears,  sees,  and  smells  ;  and  should  we  meet  the 
sensorial  delirium  with  arguments  of  reason,  we  generally  receive  answers 
as  Leuret  did  from  one  of  his  patients  (''  Fragments,'  p.  203)  : — "  I  hear 
voices  because  I  hear  them — how  they  originate  I  know  not,  but  to  me  they 
are  as  distinct  as  your  own  voice  ;  if  I  admit  the  reality  of  your  words, 
you  must  also  allow  me  to  believe  in  the  reality  of  those  voices,  as  to  me 
both  are  equally  appreciable."  Thus,  in  the  opinion  of  the  subject  of 
the  hallucination  his  subjective  sensitive  perceptions  have  commonly  the 
same  reality  as  the  objective  perceptions  presented  by  the  external  world, 
and  to  this  very  circumstance  is  in  a  great  measure  due  the  importance 
and  danger  of  the  phenomena.  We  are  accustomed  to  trust  our  senses, 
to  consider  that  as  most  true  which  we  ourselves  see  or  touch  ;  he  in 
whom  false  sensorial  j^erceptions  are  substituted  for  those  which  are  true, 
and  the  material  of  his  ideas  and  their  combination  thereby  falsified, 
enters  a  new  sphere  of  appearances  and  of  falsehood.  He  cannot  distin- 
guish them  from  the  objective  reality,  according  to  which  he  regulates 
his  thoughts  and  acts,  and  in  general  it  cannot  be  forced  on  him  by  the 
opinion  of  a  stranger ;  he  is  compelled  to  follow  the  decej^tion,  because 
to  him  it  has  the  force  of  sensorial  conviction;  and  not  only  are  the  most 
crazy  and  stupid  ideas  awakened  and  maintained  in  him,  but  very  often 
the  most  dangerous  misdeeds  result  from  the  hallucinations. 

The  subject  of  hallucinations  may,. at  any  moment,  be  incited  by  voices  or 
visions  to  inflict  violence  on  himself  or  others;  for  example,  to  murder  in  conse- 
quence of  having  had  a  command  from  God  to  deeds  of  vengeance  for  abusive 
language  which  he  has  heard,  etc.  The  majority  also  of  the  crimes  committed 
by  the  insane  depend  on  hallucinations,  a  circumstance  which,  from  the  great 
frequency  of  hallucinations,  is  not  to  be  wondered  at.  According  to  Esquirol,. 
80  in  every  100  patients  have  hallucinations;  Falrrt  (' Leg.  Clin,  de  Med.  Ment.,' 
Paris,  1854,  page  151)  gives,  of  course,  a  much  lower  proportion — about  a  third 
of  the  number  of  the  patients. 


THE    ELEMENTARY    DISORDERS    IN    MENTAL  DISEASE.  61 

§  54.  Subjective  sensorial  function  is  in  itself  not  extraordinary; 
sensation  originating  through  internal  irritation,  without  external  cause, 
is  rather  an  everyday  occurrence  ;  our  inner  world  of  sense  is  ever  active ; 
indeed,  all,  even  abstract,  thouglit  is  accompanied  by  an  inward  hearing 
and  seeing  as  an  evident  essential  element  of  normal  mental  life.  But 
the  sensations  which  thus  originate  are  generally  very  weak,  and  this  is 
wh'^-^  distinguishes  them  from  the  external  perceptions  ;  indeed,  during 
sleep,  when  the  sensations  originating  internally  cannot  be  compared 
with  jieripheral  impressions,  they  often  assume  for  us  the  strength  and 
the  character  of  external  sensations,  also  during  waking  they  may  by 
degrees  become  stronger  and  more  active,  and  at  last  resemble  reality. 
These  constitute  the  pathological  states  of  irritation  t'^  the  nervous 
system. 

Physiology  shows  that  the  nerves  of  special  sense  react  towards  all 
irritation  according  to  their  own  inherent  energy.  The  compressed  or 
■congested  retina  gives  light,  the  irritated  auditory  nerve  sensations  of 
sound,  etc.  Shall  we,  therefore,  consider  hallucinations  as  tlie  simple 
results  of  irritation  of  the  peripheral  exj^ansions  of  the  corresponding 
nerve?  This  is  impossible,  in  the  first  place,  and  principally  because 
hallucinations  c?.n  exist  where  there  is  suspension  of  the  perii^heral 
sensorial  function  ;'  and,  secondly,  because,  according  to  all  known  fact, 
by  direct  irritation  of  these  nerves — for  example,  tlie  retina — there  can 
be  produced  flashes  of  liglit,  globes  of  fire,  colored  images,  etc.,  but  no 
definite  complex  forms  (mei^..  houses,  trees,  etc.);  in  the  ear  a  humming 
noise,  high  or  low  sounds,  but  no  formed  words  or  tunes.  For  the  latter, 
something  more  is  needed,  namely,  the  co-operation  of  the  perception, 
from  which  alone  such  forms,  retained  from  former  impressions  or  pro- 
duced anew,  can  come.  This  jDrojection  of  the  perception,  by  which  the 
corresponding  sensorial  images  enter  our  mind,  this  penetration  of  the 
internal  sensorial  function  into  the  perception  by  which  the  latter  receives 
the  appearance  of  the  sensation,  we  have  learned  (§  18)  to  consider  as 
the  function  of  the  imagination;  but  while,  as  a  rule,  these  acts  are 
such  that  in  the  field  of  vision  only  ideal  outlines  and  forms  arise,  conse- 
quently only  weakened  faded  images  arc  conserved,  so  here  in  pass- 
ing through  numerous  transitions  of  strength  and  vivacity,  the  percej)- 
tion  awakens  strong  sensorial  function,  so  that  only  the  things  imagined 

'  The  observations  of  Esquirol  upon  this  point  deserve  to  be  fully  commu- 
nicated. "  I  once  had  vinder  my  care  an  old  merchant,  who,  after  a  very  active 
life,  was  seized  with  black  cataract  in  his  forty -fourth  year.  Some  years  after- 
wards he  became  insane  r  he  was  very  agitated,  spoke  loudly  with  persons  whom 
he  thought  he  saw  and  heai'd.  He  saw  the  most  wonderful  things,  and  was 
often  quite  enchanted  with  his  visions.  There  was  in  Salpetriere  a  Jewess,  aged 
thirty-eight,  who  was  blind  and  a  maniac.  Nevertheless,  she  saw  the  strangest 
things.  She  died  suddenly.  I  found  on  examination  of  the  body  the  optic  nerves 
atrophied  in  their  ivhole  course.  Certainly,  in  this  case,  transmission  of  impressions 
was  impossible.  It  is  the  same  with  the  deaf  who  think  they  hear  persons  speak. 
We  have  at  present  in  Salpetriere  two  women  absolutely  deaf,  who  have  no  other 
false  ideas  than  those  of  hearing  various  persons,  with  whom  they  dispute  night 
and  day;  they  often  become  even  furious."  (Esquirol,  '  Maladies  Mentales,'  vol. 
i.,  page  195).  More  recent  cases  of  hallucinations  of  sight  with  atrophy  and  de- 
generation of  the  optic  nerve  have  been  published  by  Johnson  ('  Med.-Chirurg. 
Reviev/,'  1836);  Romberg,  '  Nervenkrankheiten,'  3d  edition,  p.  138);  Bergman 
(Gottinger  '  Naturforscherversammlung,'  1854;  '  Psychiatr.  Corresp.-bl.,'  i.,  No. 
8,  Beil);  Leubuscher,  1.  c,  p.  33.  Calmeil  and  Foville  have  also  observed  such 
cases.  Tlie  report  of  the  Vienna  Asylum  ("Wien,  1858,  p.  46)  contains  two  cases 
where,  in  blindness  of  one  eye  through  atrophy  of  the  globe,  the  same  hallucina- 
tions affected  the  diseased  as  the  healthy  eye. 


62  THE    ELEMENTAKY    DISORDERS    IN    MENTAL    DISEASE. 

are  really  clear  and  colored,  articulate  and  melodious.  The  seat  of  all 
these  acts,  the  seat  of  the  imagination,  is  not  the  retina  nor  the  ramifi- 
cations of  the  auditory  nerve  ;  it  is  within  the  brain,  and  doubtless  it  is 
the  central  expansion  of  the  nerves  of  sense  ;  therefore,  in  accordance 
with  important  observations,  Ave  must  consider  hallucinations  as  intra- 
cerebral phenomena. 

But  this  does  not  exhaust  the  question;  there  are  many  other  facts — 
all  specially  evident  in  hallucinations  of  sight — which  indicate  that  the 
peripheral  expansions  of  the  nerves  of  sense,  when  intact,  are  concerned 
in  sensorial  delirium;  on  the  one  hand,  morbid  action  in  the  eye,  involv- 
ing the  retina,  appears  to  originate  the  production  of  hallucinations  (or 
rather  illusions,  Avliich  in  this  case,  however,  cannot  be  distinctly  sepa- 
rated from  hallucinations).  This  is  especially  seen  in  cases  where,  with 
opacity  of  the  transparent  media  of  the  eye,  hallucinations  of  sight  exist.' 
and  where  it  would  appear  that  the  imagination  seizes  upon  those  indis- 
tinct, dissolving,  cloudy  images,  which  the  retina  receives  as  material 
belonging  to  it  to  transform  them  into  imaginary  combinations.  On  the 
other  hand,  however,  those  cases,  by  no  means  rare,  where  hallucinations 
of  sight  can  be  made  to  disappear  by  covering  the  eyes,  show  that  the 
intact  retina  can  take  a  certain  part  in  the  production  of  these  phenom- 
ena; sometimes  even  where  the  axes  of  vision  are  not  parallel,  hallucina- 
tions are  seen  double — at  all  events,  there  are  cases  where  hallucinations 
exist  only  on  one  side.  Michea  mentions  such  cases  ;  I  myself  have 
observed  a  case  where  hallucinations  of  hearing  continued  during  the 
whole  duration  of  the  insanity,  and  were  only  of  the  left  side.  In  the 
cases  communicated  by  Kieser  ('Zeitschrift  fiir  Psychiatric,'  x.,  1853),  of 
hallucinations  of  hearing  of  many  years'  standing,  the  majority  were  of 
the  right  side;  sometimes  opposite  phantasms  of  different  senses,  such  as 
hallucinations  of  sight  of  the  right  side,  with  hallucinations  of  hearing 
of  the  left  side,  are  seen. 

Cases  where  the  hallucinations  of  sight  ceased  on  covering  the  eyes  are  known 
in  considerable  number.  A  young  man  saw  ai-ound  him  ail  the  personages  of 
the  court;  he  threw  himself  at  the  feet  of  that  one  whom  he  considered  the  king; 
I  allowed  the  eyes  to  be  bound  for  two  days,  and  his  delirium  ceased.  When  the 
bandages  were  taken  away  it  commenced  anew.  (Esquirol.)  Reil  ('  Rhapsodies ') 
relates,  "A  young  lady  who  saw  apparitions  and  monsters  fell  into  delirium 
with  convulsions.  Her  maid,  in  order  to  maintain  her  in  the  upright  position, 
laid  Iier  hand  upon  the  eyes  of  the  patient,  who  at  once  called  out,  '  I 
am  healed! '  This  was  repeated  next  day  by  the  physician  with  the  same  result." 
(Esquirol.) 

"  D — ,  set.  75,  mentally  healthy,  came  home  one  day  terrified  by  a  thousand 
visions  which  followed  him.  Wherever  he  looked,  the  objects  changed  them- 
selves into  frightful  images;  sometimes  monstrous  spiders  which  grasped  at  him 
in  order  to  suck  his  blood,  sometimes  soldiers  with  halberds,  etc.  Venesection 
was  performed  on  the  foot;  still  the  hallucinations  remained,  and  he  could  not 
sleep.  A  bandage  was  laid  over  the  eyes,  and  they  at  once  ceased,  and  returned 
as  soon  as  the  bandage  was  removed  until  the  patient  continued  its  use  without 
interruption  for  a  night  and  part  of  a  day.  He  now  saw  the  phantasms  only  at 
long  intervals,  and  after  a  few  days  they  totally  disappeared.  Since  then,  the 
man  has  remained  healthy."  ('  Bulletin  de  Therapeutique,'  1842.)  The  visions  of 
Nicolai  also  disappeared  on  shutting  the  eyes.''' 

'  See  the  well-known  case  related  by  Bonnet  (Essai  Analytic  sur  I'Ame,'  chap. 
23),  of  a  person  who  had  both  eyes  operated  on  for  cataract,  and  could  only  dis- 
tinguish objects  with  the  right  eye.  He  had  the  most  lively  hallucinations  of 
sight  without  believing  In  their  reality.  In  the  case  of  a  patient  whom  I  saw  in 
Tiibingen  there  was  cataract  in  both  eyes,  and  his  insanity  was  characterized 
almost  entirely  by  the  most  manifold  hallucinations  of  sight. 

'■^  See  also  '  Leuret,'  loc.  cit.,  p.  147. 


1 


THE    ELEMENTARY    BISORDEKS    IN    MENTAL    DISEASE.  63 

These  cases,  which  are  the  opposite  of  hallucinations  in  the  blind,  may  be 
regarded  as  illusions;  whereby,  however,  our  physiological  knowledge  of  them  is 
not  much  advanced.  Thej-  may  be  viewed  as  a  centrally  provoked  simultaneous 
hallucination  of  the  retina  surface  according  to  a  scheme  given  by  the  imagina- 
tion; this  view  has,  indeed,  its  difficulties,  but  it  is  also  supported  by  the  fact 
that  surrounding  objects  are  often  seen  through  the  phantasms  of  sight  as 
through  a  veil. 

That  it  is  perceptions  which  give  form  and  body  to  the  sensorial  functions  is 
especially  shown  by  the  circumstance  that  certain  observei"s  can  voluntarily  call 
forth  hallucinations,  that  is,  that  detinite  and  lively  ideas,  previously  existing  in 
the  state  of  consciousness,  first  excited  the  sensorial  functions.  An  individual 
who  had  hallucinations  of  hearing  remarked  that  he  could  himself  call  forth  the 
words  which  the  voices  subsequently  spoke,  and  this  aided,  him  in  recognizing 
them  as  deceptions  (Holland,  '  Chapter  on  Mental  Physiol.,'  2d  ed.,  p.  52).  The 
communications  of  Sandras  are  also  very  remarkable  (' Ann.  Med.  Psych.,' vii., 
1855,  p.  542)  regarding  special  hallucinations  in  a  disease  where  the  special 
thoughts  and  requirements  were  heard  as  voices.  The  voice  answered  to  mental 
questions  of  the  patients  as  a  third  person,  but  always  replied  in  the  sense  of  his 
wishes.  Intelligent  patients  also  often  tell  us  that  at  tirst  tliey  are  spoken  to 
ideally,  "mentally;"  it  is  not  till  a  later  period  that  the  voices  really  become 
audible. 

Certain  observers  have  questioned  the  idea  of  the  imagination  being  the  cause 
of  hallucinations,  by  calling  attention  to  the  difference  which  exists  between 
them  and  the  simple  fancies  ( Leuret,  Hagen).  This  objection  fails,  inasmuch  as 
we  (§  8)  consider  the  phenomenon  of  the  imagination  as  being  one  of  the  func- 
tions of  the  internal  sensorial  appai'atus,  but  differing  from  the  otliers  in  strength 
(see  Miiller,  loc.  cit.y  i.,  5). 

Doubtless  there  is  still  a  great  difference  between  an  hallucination  and  that 
internal  excitation  of  the  imagination  which,  for  example,  the  artist  has  in  the 
conception  of  his  work  of  art;  the  hallucinations  are  considered  as  externally 
real — they  are  in  the  eye,  in  the  ear.  It  may  be  asked,  is  this  difference  there- 
fore specific,  or  is  it  only  an  affair  of  degrees  ?  In  the  first  place,  there  would 
be  in  the  hallucination  the  co-operation  of  a  special  act,  which  is  wanting  in  the 
so-called  excitation  of  the  imagination.  I  consider  the  assumption  of  simple 
difference  in  degrees  as  the  correct  one.  We  see  from  the  exact  description  of 
their  hallucinations,  which  the  insane  give  us,  that  they  may  range  from  the 
most  faded  and  shadowy  appearances  even  to  the  greatest  sensuous  vivacity,  and 
it  is  not  so  very  unusual  for  artistic  excitation  of  the  imagination  to  proceed  to 
sensuous  appearances,  although  they  may  be  light  and  pale. 

I  have  seen  an  interesting  transformation  of  that  obscure,  pale,  internal  hal- 
lucination, which  accompanies  perception  in  ordinary  states  into  hallucinations 
with  real  objective  distinctness,  in  a  patient  who  was  extraordinarily  rich  in 
visions,  and  delighted  in  them.  He  often  spoke  of  them,  saying  that  many  of  his 
appearances  existed  only  m  outline,  without  color;  others  as  obscure,  cloudy 
images;  and  others  as  lively  colored  images,  fully  corresponding  to  actual  external 
objects. 

Lelut  also  (loc.  cit.)  very  correctly  calls  hallucinations  complete  transforma- 
tions of  thought  into  external  sensorial  impressions;  and  the  anwer  is  very 
Bignificant  which  a  melancholic  gave  to  Esquirol,  who  spoke  to  him  regarding 
the  falseness  of  his  hallucinations  of  hearing.  "  During  conversation,  he  said 
tome, 'Do  you  think  sometimes?'  '  Without  doubt,'  said  I.  'Very  well;  you 
think  quite  quietly,  and  I — I  think  aloud.'" 

An  intelligent  patient  whom  I  have  previously  mentioned  (a  medical  student), 
who  had  throughout  hallucinations  of  the  left  side  during  a  violent  attack  of  in- 
sanity, had  the  impression  that  the  voices  did  not  come  from  the  immediate 
neighborhood;  he  had  estimated  them  at  a  distance  of  several  minutes.  He  also 
made  the  remarkable  declaration  that  he  could  by  his  belly  exercise  voluntarily 
an  influence  on  the  hallucinations  of  hearing.  On  closer  investigation,  it  was  seen 
that  he  meant  the  respiratory  function  of  the  abdominal  muscles,  and  that  it  was  by 
means  of  the  respiration  that  he  exercised  the  influence.  On  holding  the  breath 
the  voices  were  often  changed — appeared  to  come  from  a  point  nearer  or  more  dis- 
tant. We  know  that  in  expiration  the  cerebro-spinal  fluid  rises  from  the  spinal 
canal  into  the  cavities  of  the  brain  and  subarachnoid  space  (owing  to  the  filling  of 
the  numerous  venous  plexuses  of  the  canal  of  the  spinal  marrow),  and  that  it  again 
subsides  during  inspiration. 


64:  THE    ELEMENTARY    DISORDERS    IK    MENTAL    DISEASE. 

§  55.  The  different  behavior  of  an  individnal  in  regard  to  his  halhi- 
cinations  may  depend,  in  part,  on  slight  differences  of  a  certain  kind,  in 
the  strength  and  clearness  of  the  false  perceptions,  compared  with 
objective  sensorial  impressions.  Far  more  inflnence,  however,  is  ex- 
erted in  this  respect  by  the  state  of  tlie  cerebral  functions  generally,  in 
so  far  as  they  permit  a  greater  or  less  degree  of  reflection,  and  by  the  de- 
gree of  education  and  the  former  views  of  life  of  the  patient. 

Hallucinations  are  not  entirely  confined  to  states  of  mental  disease. 
It  is  well  known  that  in  dreams — to  which  we  shall  again  refer — inebria- 
tion, vertigo,  and  analogous  states,  phantasms  of  sight  are  produced. 
But  even  exclusive  of  these  states,  hallucinations  are  not  uncommon  ir 
persons  not  insane.  The  well-known  case  of  Nicolai,  the  fact  befort 
quoted  from  Bonnet,  several  of  the  cases  mentioned  by  Patterson,  all  re- 
ligious visions,  etc.,  are  examples  of  this.  Nothing  would  be  more  erro- 
neous than  to  consider  a  man  to  be  mentally  diseased  because  he  had 
hallucinations.  The  most  extended  experience  shows  rather  that  such 
phenomena  occur  in  the  lives  of  very  distinguished  and  highly  intellectual 
men,  of  the  most  different  dispositions  and  various  casts  of  mind,  but  es- 
pecially in  those  of  warm  and  powerful  imagination.  Tasso,  who  in 
presence  of  Manco  carried  on  a  long  conversation  with  his  protecting 
spirit — Goethe's  well-known  (blue-gray)  vision,  and  his  ideal  flowers  with 
their  curious  buds — Sir  Walter  vScott's  apparition,  in  which  his  dead 
friend  Byron  stood  before  him  in  the  folds  of  a  curtain— Jean  Paul,  who 
saw  the  head  of  a  little  girl  looking  down  from  the  window' — Benvenuto 
Cellini's  vision  of  the  sun — may  serve  as  an  example  from  the  life  of 
artists.  Spinoza,'^  Pascal,'  had  hallucinations;  Van  Helmontsawhis  own 
soul  in  the  form  of  a  light  Avith  a  human  coutenance;  Andral*  tells  tluit 
he  himself  had  an  hallucination  of  sight,  and  Leuret  that  he  has  experi- 
enced a  phantasm  of  hearing.^  Indeed,  judging  from  what  we  have 
heard  and  observed  on  this  sul)ject,  hallucinations  doubtless  occur  also  in 
men  of  very  average  minds,  not  as  rare,  but  us  frequently  overlooked  phe- 
nomena.^ 

The  man  who  is  mentally  healthy  either  views  such  hallucinations 
with  calmness  and  consideration,  because  he  recognizes  them  as  origi- 
nating subjectively  (Nicolai  and  others),  or  he  believes  in  their  reality, 
either  because  his  reflection  does  not  possess  the  premises  necessary  to 
judge  of  these  phenomena,  because  superstition,  sluggishness  of  thought, 
love  of  the  marvellous,  obscure  and  restrict  their  correct  interpretation; 
or  because  certain  dispositions,  passions,  and  emotions  (fear,  anger,  joy, 
etc.),  susjiend  reflection  and  calm  consideration;  or  even  because  they 
are  borne  out  by  hallucinations  of  several  senses,  of  sight,  of  hearing,  of 
cutaneous  sensibility,  and  thus  the  means  of  rectifying  one  of  the  errors 
is  itself  falsified. 

Hallucinations  alone,  even  when  considered  true,  are  not  sufficient  to 
constitute  insanity.  For  this  there  must  also  exist  a  general  profound 
perversion  of  mind  or  fully  developed  insane  ideas.     In  order,  however, 

'  Jean  Paul,  '  Glimpses  into  the  Dream-world. ' 

'^  Spinoza,  Epistle  XXX.  to  Peter  Balling. 

^  Ever  after  a  dangerous  fall  from  the  bridge  of  Neuilly  Pascal  saw  an  abyss 
before  him. 

■* '  Special  Pathology.' 

^  '  Fragments  Psycholog.,'  p.  135. 

*  For  further  examples  of  hallucinations  in  healthy  persons,  see  Lahr, '  Irresein,' 
p.  32. 


THE    ELKMENTAKY    DISORDERS    IN    MENTAL    DISEASE.  65 

to  consider  hallucinatious  as  true,  it  is  necessary  that,  thanks  to  them, 
the  whole  of  the  healthy  sensorial  ])erceptions  be  perverted;  and  there- 
fore, hallucinations,  when  considered  as  true,  are,  of  course,  a  very  near 
step  to  insanity,  and  especially  where  a  morbid  perversion  already  exists. 
In  the  still  moderate  commencing  stages  of  insanity  the  hallucinations 
tix  and  root  themselves  so  easily  that  very  often  they  are  then  considered 
as  causes  of  the  entire  disease.  According  to  our  o^nnion,  it  is  only  in 
rare  cases  that  we  can  assign  to  them  this  jiosition.  We  believe,  rather, 
that  hallucinations  must  be  considered  as  symptoms  of  already  existing, 
although  perhaps  still  moderate,  irritation  of  the  brain.  At  all  events, 
however,  the  fact  is  correct,  that  they  very  often  appear  in  the  first 
period  of  insanity,  and  that  with  the  appearance  of  hallucinations,  with 
the  falsifying  of  the  external  world,  the  patient  frequently  first  begins 
really  to  become  delirious. 

In  mental  disease  hallucinations  are  almost  invariably  considered  as 
realities.  Still,  in  occasional  cases,  especially  at  the  commencement, 
the  patient  admits  their  morbid  nature.  Sometimes,  indeed,  we  hear  the 
patients  declare  that  they  know  very  well  that  it  is  no  ordinary  hearing 
or  seeing,  it  is  a  mental  hearing* — some  one  "composes  to  him  in  his 
head,"  etc.,  or  he  complains  bitterly  that  the  malice  of  strangers,  the 
,  medicines  which  he  has  taken,  etc.,  have  caused  such  wicked  appearances, 
and  he  expresses  in  his  own  peculiar  way  the  idea  that  he  is  governed  ly 
something  in  his  mind  which  is  opposed  and  perfectly  foreign  to  his  /. 
The  most  remarkable  cases,  however,  are  those  in  which  the  patient 
knows  and  can  give  tlie  subjective  origin  of  his  hallucinations,  and  yet  con- 
siders them  as  realities.  Sometimes  they  say  that  the  voices  proceed  from 
within  their  head."  At  other  times,  and  very  frequently,  it  seems  to  the 
patient  as  if  the  voices  proceed  from  the  epigastrium,  and  as  if  he  were 
spoken  to  from  there — true,  not  in  the  ordinary  manner,  but  in  quite  a 
new  way.'  In  all  such  statements  much  depends  on  the  patient's  capabil- 
ity of  self -observation  and  of  describing  his  mental  state. 

In  mental  disease  hallucinations  are  generally  at  first  circumstances  of 
great  attention,  and  very  harassing  and  troublesome  to  the  patient. 
After  a  time,  from  habit,  they  become  less  engrossing,  but  they  often  at- 
tain such  a  degree  of  independence  that  they  remain  isolated  after  the  dis- 
ease has  run  its  course,  and  may  impede  the  complete  return  to  mental 
health;  owing  to  the  hallucinations,  also,  such  patients  avoid  all  inter- 
course with  the  world,  and  therefore  fall  into  a  state  of  mental  poverty.* 

We  shall  here  mention  a  few  examples  of  hallucinations  occurring  in  individ- 
uals not  insane. 

Mr.  H —  one  day  was  reading  Commine's  '  History  of  Burgundy.'  Looking 
towards  the  window  he  saw  a  skull  lying  on  a  chair  ;  he  thought  of  calling  out 
to  inquire  who  had  put  it  there,  but  he  first  went  towards  it  in  order  to  examine 
it.  As  he  put  out  his  hand  to  grasp  it  it  disappeared.  He  was  terrified  almost  to 
fainting.  Fourteen  days  afterwards  he  again  saw  in  a  lecture-room  in  the  College 
at  Edinburgh  a  skull  lying  on  the  desk,  and  said  to  his  neighbor,  "  What  will  the 


'  Also  Shakespeare  makes  Hamlet  reply  to  Horatio's  question  where  he  saw 
the  ghost,  '  In  my  mind's  eye,  Horatio.' 

^  "  C'est  un  travail  qrn  se  fait  dans  ma  tete,"  Leuret,  loc.  cit.,  p.  162.  I  too 
have  seen  such  a  case.  The  patient  heard  several  men  speaking  together  in  his 
head  ;  he  sometimes  also  thought  that  a  whole  tableful  of  persons  sat  at  meat 
somewhere  in  the  neighborhood  of  his  cardiac  region. 

2  Leuret,  loc.  cit.,  p.  177.  In  another  case  (Lafargue,  '  Gaz.  Med.,'  1841,  p. 
713)  the  hallucinations  of  hearing  came  from  the  neighborhood  of  the  heart. 

*  See  Neumann,  '  Psychiatrie,'  p.  119. 

5  ..„     , 


66  THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE. 

professor  do  with  a  skull  to-day  ?  "  Another  time  Mr.  H—  was  present  at  the 
post-mortem  examination  of  a  friend.  Three  months  after,  when  going  to  bed, 
he  found  an  invitation  to  the  funeral  of  the  mother  of  his  friend  lying  on  the 
table.  Scarcely  had  he  put  out  the  light  when  he  felt  himself  seized  by  the  arm 
below  the  shoulder,  and  it  pressed  strongly  against  his  side.  He  sought  to  free 
himself,  and  cried,  "  Let  go  my  arm  ;"  he  then  heard  distinctly  a  voice,  "  Be  not 
afraid."  He  immediately  answered,  "  Allow  me  to  strike  a  light."  The  arm  was 
then  set  free.  H —  rose,  but  felt  violent  vertigo  and  great  weakness.  When  he 
had  lighted  a  lamp  he  saw  the  countenance  of  his  friend  at  the  door,  but  it  was 
indistinct,  as  if  a  veil  were  over  it.  As  Mr.  H —  approached,  the  figure  withdrew; 
he  followed  it  down  the  steps  to  the  outer  door,  where  he  fell  in  a  fainting  fit. 
He  was  afterwards  seized  with  violent  pain  over  the  eyebrows,  fever,  and  sleep- 
lessness. 

A  Southerner  in  the  prime  of  life  and  in  perfect  health  paid  a  visit  one  day  to 
a  neighbor.  As  he  was  entering  the  door  there  passed  before  him  the  figure  of  a 
woman  clothed  in  white,  and  immediately  a  second,  then  a  third.  He  stretched 
out  his  hand  to  seize  the  last,  and  it  disappeared.  Shortly  after,  the  man  was 
walking  through  a  park  in  which  he  saw  several  asses  grazing  ;  he  wished  to  pat 
one  of  them  on  the  back,  and  was  much  surprised  when  he  found  that  he  could 
feel  nothing ;  they  still  remained  before  his  eyes,  and  he  several  times  in  vain 
repeated  the  attempt  to  touch  them. 

The  following  case  affords  a  striking  example  of  numerous  hallucinations  and 
illusions  in  a  lunatic,  and  shows  how  false  ideas  originate  from  them  (Bergmann, 
''Remarks  of  a  Person,  who  had  been  Insane,  on  his  Morbid  Mental  State," 
TYiedrich's  '  Archiv  fiir  Psychologic,'  1834,  i.,  p.  15). 

"  Once  there  was  a  storm,  but  such  a  storm  as  I  have  never  seen  before  nor 
since.  The  clouds  appeared  to  me  to  be  waves  of  the  sea  elevated  into  the  air, 
where  they  fought  with  each  other,  while  an  enemy's  fleet  commenced  a  mortal 
combat  with  the  inhabitants  ;  this  was  the  decisive  moment  for  the  salvation  of 
Holland,  which  appeared  to  me  to  be  already  completely  lost.  I  heard  no  thun- 
der, saw  no  lightning,  but  saw  the  flashes  of  cannon  and  heard  their  loud  reports 
rapidly  succeeding  each  other.  Afterwards,  on  emptying  my  linen  and  clothes 
out  of  my  box,  I  saw  an  extraordinary  quantity,  and  also  a  table-cover  which  had 
been  left  behind  at  C — .  As,  on  another  day,  many  things  were  wanting  which  I 
believed  I  had  in  my  hands,  I  thought  they  must  have  been  stolen.  One  evening 
I  lay  in  bed,  following  with  my  eyes  the  maid  servant,  whom  I  supposed  to  be  a 
ghost ;  then  the  tallow  of  the  candle  began  to  run  very  fast ;  I  saw  the  tallow, 
however,  run,  not  from  the  candle,  but  from  a  hole  in  the  wall,  and,  indeed,  in 
such  quantity  as  to  resemble  a  constant  stream.  I  then  declared,  with  a  scream, 
that  I  would  be  suffocated.  Hereupon  I  fell  into  the  delusion  that  the  air  was 
poisoned,  and  from  that  moment  I  constantly  felt  a  sweetish  disagreeable  odor, 
which  I  tasted  in  all  food,  and  formed  the  opinion  that  the  beef  brought  to  me 
was  human  flesh.  The  buildings  which  I  could  see  from  my  room  appeared  to 
be  a  small  clay  pipe,  which  evidently  projected  above  out  of  the  chimney,  and 
therefore  engendered  in  me  the  frightful  idea  that  this  pipe  was  the  only  place  by 
which  air  could  enter.  Therefore  all  who  entered  were  supposed  by  me  to  be 
doomed  to  suffocation." 

§  56.  In  the  consideration  of  the  more  immediate  circumstances 
under  which  hallucinations  appear,  the  following  causes  are  especially  to 
be  kept  in  view. 

(1)  Local  disease  of  an  organ  of  sense  may  become  the  source  of  sen- 
sorial delirium;  therefore  it  is  always  necessary  minutely  to  examine  the 
patient  in  this  respect. 

(2)  All  states  of  deep  exhaustion,  whether  of  mind  or  of  body,  appear 
to  favor  the  development  of  hallucinations.  As,  in  former  times,  the 
strong  asceticism  from  religious  motives  was  a  cause  of  numerous  halluci- 
nations, so  at  the  present  time  we  very  frequently  see  the  sensorial  delir- 
ium coming  on  after  inanition,  prolonged  fasting,  or  other  exhausting 
cause,  great  mental  fatigue,  etc.  This  is  particularly  favored  by  one- 
sided mental  concentration,  by  superstitious  ideas  when  fervently  main- 
tained (Benvenuto  Cellini,  many  devils  and  religious  visions). 

(3)  The  morbid  emotional  states  from  which  insanity  so  frequently 


THE    ELEMENTARY    DISORDERS    IN    MENTAL    DISEASE.  67 

originates  evoke  hallucinations  and  illusions  in  the  same  manner  as  the 
analogous  states  in  health,  fear,  fright,  etc.,  obscure  the  sensorial  per- 
cei^tion  and  awaken  new  and  false  sensorial  images. 

(4)  Outward  calm  and  stillness  favor  hallucinations,  and  the  produc- 
tion of  hallucinations  between  sleeping  and  waking  is  a  circumstance  of 
special  importance.  Their  aj^pearauce  under  such  circumstances  in 
health  is  well  known,  and,  in  particular,  J.  Miiller's  description  of  these 
events  from  personal  experience  is  frequently  referred  to  by  physiologists.  * 
Observation  shows  that  also  in  the  mentally  diseased  they  very  often  origin- 
ate during  sleep,  and  especially  that  their  first  commencement  often 
dates  from  the  time  of  sleep.  °  If  they  have  lasted  for  a  considerable  time 
under  these  circumstances  in  the  commencing  periods  of  insanity,  they 
often  become  persistent,  appearing  also  when  the  patient  is  fully  awake, 
and  exciting  false  ideas.  In  certain  rare  cases,  however,  an  attack  of 
mania  has  been  seen,  even  on  the  first  day,  to  succeed  hallucinations 
appearing  between  sleei^ing  and  waking.  As,  however,  even  the  simple 
closing  of  the  eyes  occasionally  suffices  to  call  forth  hallucinations  in  those 
who  are  disposed  to  them  (Goethe  and  J.  Miiller  say  this  of  themselves^), 
so  it  has  been  found  that  also  in  the  insane  simple  closing  of  the 
eyelids  causes  hallucinations  to  appear  (Bailiarger,  loc.  cit. ).  Those 
cases  spoken  of  in  §  53,  where  the  phantasms  of  sight  disappeared  on 
closing  the  eyes,  again  remind  us  of  the  great  variety  which  exists  in  the 
complex  phenomena  of  the  hallucinations. 

The  cases  are  by  no  means  rare  where  at  the  commencement  of  the  insanity 
the  patients  made  light  of,  or  resisted,  the  rising  and  as  yet  fleeting  insane  ideas  ; 
wrlien  tliey  turned  them  over  in  their  mind,  and  perhaps  affirmed  or  perhaps 
rejected  them.  Some  night,  when  the  hglit  is  put  out,  when  in  the  still  of  night 
all  is  externally  calm  to  the  ear,  the  first  hallucinations,  the  voices,  appear  which 
confirm  the  insane  ideas,  and  these  thereby  receive  the  force  of  sensorial  con- 
viction. 

(5)  Certain  poisons  and  substances  used  in  medicine  can  very  effect- 
ually call  forth  hallucinations,  especially  the  preparations  of  hemp,  bella- 
donna, stramonium,  etc. 

Although  these  are  instructive,  as  they  show  that  phenomena  can  in  part  be 
called  forth  at  will  and  be  made  subjects  of  experiment,  yet  they  have  no  special 
relation  to  the  hallucinations  of  the  insane,  and  it  is  sufficient  merely  to  have 
mentioned  them. 

§  57.  The  forms  of  the  various  hallucinations  depend,  as  a  rule,  upon 
the  present  disposition  of  mind  and  direction  of  the  thoughts.^  This 
also,  to  a  great  extent,  decides  whether  they  be  gay  or  sad;  and  sensorial 
delirium  is  rarely  altogether  independent  in  its  nature.  The  melancholic 
frequently  hears  language  of  reproach  or  menace,  or  voices  which  call  on 
him  to  perform  some  atrocious  act;  in  mania,  the  hallucinations  sanction 
the  excited  state  of  mind.  In  short,  the  ruling  emotion  (fear,  jealousy, 
joy,  etc.)  determines  the  form  of  the  phantasms.  This  circumstance  is 
important  in  a  prognostic  point  of  view.     Observation  shows  that  hallu- 

'  See  Miiller,  '  Phantastische  Gesichtserscheinungen  ;'  Blumroder,  '  Ueber  Ein- 
schlafen  ;'  Traum  ;  Schlaf,  in  Friedrich's  '  Magazin,'  1830,  iii.,  p.  87. 
^Bailiarger,  'Archives  Gener.,'  1842,  p.  354. 
3  Miiller,  loc.  cit.,  p.  21-27. 

^  Shakespeare  makes  Macbeth  say,  when  he  would  seize  the  dagger — 

"  There's  no  such  thing  ; 
It  is  the  bloody  business  which  informs 
Thus  to  mine  eyes." 


68  THE    ELEMENTAKY    DISORDERS    IN    MENTAL    DISEASE. 

cinations  depending  in  tliis  way  on  a  certain  morbid  emotional  state,  can 
again  disappear  on  removal  of  that  state;  while  independent  hallucina- 
tions— not  connected  with  emotional  states — seldom  admit  of  real  cure, 
and  generally  enter  as  essential  elements  into  the  state  of  chronic  mania. 

In  states  of  great  weakness,  after  long  pain,  before  death,  etc., 
joyous  brilliant  hallucinations  are  often  observed.  Various  other  organic 
conditions— irritation  of  the  genital  organs,  want  of  food,  etc. — deter- 
mine in  other  ways  the  content  of  the  sensorial  delirium  which  now  pre- 
sents adequate  images,  voices,  etc. 

The  remarkable  similarity  which  exists  between  certain  hallucinations 
produced  by  certain  similar  causes  in  well  known.  Thus,  appearances  of 
animals,  mice,  rats,  birds,  etc.,  are  very  common  in  delirium  tremens. 
We  might  be  inclined  to  consider  such  as  phantastic  transformations  of 
musccB  volitantes,  were  it  not  that,  according  to  our  observation,  large 
animals— sometimes  in  great  herds— are  also  frequently  seen;  horses, 
dogs,  ''a  million  of  cattle,"  etc.  The  illusions,  too,  Avhich  result  from 
taking  stramonium,  belladonna,  and  especially  Indian  hemp,  are  some- 
what specific. 

Hallucinations  of  a  religious  kind  are  very  common.  The  thinker 
recognizes  the  religious  element  of  his  being  in  the  images  presented  by 
his  imagination;  and  this,  the  highest  sentiment  of  the  human  mind,  he 
takes  pleasure  in  confirming  by  self-drawn  images.  In  the  mentally  dis- 
eased, voices  from  heaven,  sometimes  demanding  human  sacrifice,  some- 
times denouncing  divine  messages  to  the  poor  monomaniac,  are  very  fre- 
quent. Their  contents  vary  according  to  the  degree  of  education;  and 
much  depends  on  whether  the  individual  was  formerly  most  engrossed 
with  the  Apocalypse,  with  the  Urania  of  Tiedge,  with  Byron's  angels,  or 
with  modern  mediums.  In  general,  a  belief  in  the  reality  of  such  morbid 
visions  is  not  a  characteristic  of  this  age;  yet,  even  in  our  day  (1816),  a 
monomaniac  was  recognized  as  inspired,  not  only  by  the  masses,  but  was 
even  considered  by  an  archbishop,  and  by  a  minister  of  police,  as  an 
ambassador  from  God,  and  as  such  was  consulted  by  a  king  (Louis  XVIII.  > 
on  matters  of  state. 

See  the  history  of  the  peasant  Martin,  by  Leuret  (loc,  cit.,  p.  171).  While 
engaged  in  manuring  his  field,  a  figure  appeared  before  him,  and  summoned  him 
to  warn  the  king  of  threatened  danger  to  his  person,  and  conspiracy  against  the 
state.  After  the  affair  had  created  a  great  excitement  in  Paris,  Pinel  declared 
that  Martin  was  suffering  under  intermittent  mania  with  hallucinations;  he  was 
therefore  taken  to  Charenton;  but  there  also  he  found  disciples,  and  even  amongst 

the  physicians !  ,         „  ,    „     .     ^.  j  -n     • 

In  the  following  paragraphs,  further  examples  of  hallucmations  and  illusions 
in  the  insane  are  given  according  to  their  idiosyncrasies. ' 

§  58.  Hallucmations  of  sight. —Accovding  to  Gratiolet,  there  may  be 
distinguished  the  following  leading  varieties  in  hallucinations  of  sight: — 
(1)  Such  as  appear  in  darkness  by  night,  on  shutting  the  eyes,  or  in  the 
blind:  they  are  generally  bright,  even  fiery,  but  somewhat  pale;  the  forms 
are  very  frequently  those  of  birds,  hideous  faces,  etc.,  and  they  have  a 
tendency  to  move  to  and  fro.  (2)  Those  seen  in  dim  light  or  in  the  twi- 
light are  frequently  white  figures  which  appear  to  take  a  position  in  the 
room  at  an  appreciable  distance,  and  do  not  move  to  and  fro.  (3)  Those 
seen  by  daylight;  they  appear  generally  as  perfect  realities.  This,  how- 
ever, I  cannot  corroborate:  from  many  descriptions  of  hallucinations,  I 
assume  that  they  are  also  frequently  indistinct  and  shadow-like^ 

>  See  also  the  writings  of  Esquirol,  Hagen,  Leuret,  Sinogowitz. 


THE    ELEMENTARY    DISOKDEKS    IN    MENTAL    DISEASE.  69 

Very  often  the  patients  see  masses  of  fire  and  of  liglit;  and,  according 
to  circumstances,  according  to  the  direction  abeady  given  to  the  thoughts, 
these  appearances  are  yariously  interpreted.  One  believes  that  he  is  in 
heaven,  and  sees  the  majesty  of  G-od  in  all  its  glory;  another  believes 
himself  encompassed  by  the  flames  of  hell.  A  young  woman  at  the  period 
of  menstruation,  saw  (really)  her  parental  home  on  fire;  immediately  she 
became  furious,  would  throw  herself  into  the  fire,  knew  no  person,  and 
believed  that  she  herself  was  on  fire.  Brought  into  the  hospital,  she  filled 
the  air  with  the  perpetual  cries  of  ''Fire!"  She  thought  that  she  suf- 
fered the  pain  of  the  flames,  and  that  her  parents  were  abandoned  to 
them.  She  was  constantly  a  prey  to  delirium  and  fury,  and  cried  per- 
petually, "See  how  everything  burns!  all  the  engines  in  the  town  cannot 
put  out  the  fire — it  must  destroy  us  all!"  She  died  in  four  weeks,  and 
"Fire!  fire!  "  whei'e  her  last  words. ^ 

Another  had  a  great  number  of  visions.  The  Son  of  God  frequently 
appeared  to  him:  he  sees  him  borne  upon  clouds,  surrounded  by  angels, 
and  holding  a  cross  in  his  hand.  He  entrusts  to  him  his  commands,  but 
not  by  words,  but  by  signs,  which  appear  in  the  air.  The  patient  delin- 
eates the  forms  which  he  sees  in  the  air;  they  are  sometimes  geometrical 
figures,  sometimes  those  of  animals  or  of  household  materials,  flowers  or 
musical  instruments;  sometimes  they  are  curious  figures  to  which  nothing 
is  similar,  etc.     (Esquirol. ) 

Another  writes,  "  I  have  seen  God  the  Father  several  times.  He  had 
the  graciousness  to  speak  to  me;  He  entered  into  several  hells,  where  He 
slew  several  monstrous  beasts,  and  had  them  buried  in  holes,  from  which 
one,  I  believe,  gave  false  oracles.  I  several  times  saw  John  the  Baptist 
in  heaven,  in  a  chariot  with  seven  horses,"  etc.^ 

A  gentleman  who  had  hypochondriacal  melancholia  continually  went 
about  striking  the  furniture  of  the  room  with  his  cane,  and  the  faster  he 
went  the  more  he  struck.  I  afterwards  learned  that  he  mistook  the  shad- 
ows of  the  furniture  on  the  floor,  and  his  own  shadow,  for  rats.  There- 
fore, the  faster  he  went,  the  more  persuaded  was  he  that  the  rats  were 
increasing  in  number.     (Ibid.,  p.  129.) 

The  seat  of  hallucinations  of  sight  muet  be  the  internal  expansion  of  the  optic 
nerves.  Anatomical  observations  have  yet  to  be  made  on  this  point;  in  dissec- 
tions, the  thalainal  surfaces,  the  corpora  quadrigemina  and  their  neighborhood, 
also  the  centrum  ovale,  should  be  carefully  examined.  In  a  case  reported  by 
Bright  ('  Guy's  Hospital  Reports,'  1837)  of  a  patient,  who,  after  two  apoplectic 
attacks,  had  hallucinations  of  sight,  there  "was  found  an  inflamed  spot,  half  an 
inch  in  size,  in  the  corpus  geniculatuni,  penetrating  to  the  surface  of  the  brain. 

§59.  Hallucinations  of  hearing. — Hallucinations  of  hearing  are  not 
quite  so  common  as  those  of  sight.  They  are  most  general  in  melancholia 
and  chronic  mania,  in  which  they  are  occasionally  the  cause  of  an  attack 
of  mania.  They  are  generally  indications  of  a  more  serious,  less  curable, 
affection  of  the  brain,  and  are  often  latent  until  certain  false  ideas  have 
become  fully  fixed.  They  have  been  with  special  frequency  observed  in 
connection  with  the  diseases  of  the  abdomen  and  genital  organs.  The 
anatomical  signification  of  this  fact  would,  if  it  were  known,  perhaps  ad- 
vance our  knowledge  on  this  point  (connection  with  the  cerebellum). 
The  voices  appear  to  come  sometimes  from  a  distance,  sometimes  from  the 
neighborhood;  sometimes  from  the  earth,  the  walls,  the  furniture,  or  even 

'  Sinogowitz,  loc.  cit.,  p.  258. 

■^  Esquirol,  loc.  cit.,  p.  100-102.  See  also  a  patient's  description  of  his  visions 
communicated  by  Hirsch  in  Nasse's  '  Zeitschrift  fiir  Anthropol.,'  1852,  Heft  1. 


70  THE    ELEMENTARY    DISOKDEKS    IN    MENTAL    DISEASE. 

from  the  patient's  own  body.  Sometimes  they  continue  so  persistently 
that  the  patients  fall  into  a  state  of  desperation.  Those  who  have  hallu- 
cinations of  hearing  have  also  more  nonsensical  ideas  than  generally  result 
from  the  other  phantasms,  and  they  often  exhibit  the  most  peculiar  and 
grotesque  demeanor.  They  reply  to  the  voices  by  friendly  or  threatening 
gestures  or  words.  They  often  become  suddenly  quiet  and  attentive  in 
order  to  listen,  and  then  commit  the  oddest  and  most  dangerous  acts 
which  the  voices  have  recommended. 

A  young  man  had  not  spoken  a  word  for  six  months  after  an  attack  of  furious 
mania,  nor  performed  any  vohmtary  act.  One  day  he  seized  a  full  bottle  and 
threw  it  at  the  head  of  the  waiter.  He  remained  immovable  and  quiet,  and  after 
several  months  he  recovered.  I  asked  him  why  he  had  thrown  the  bottle. 
"  Because  I,"  said  he,  "  heard  a  voice  which  said  to  me, '  Kill  somebody,  and  you 
shall  be  delivered;'  I  did  not  kill  the  man;  therefore,  my  lot  could  not  be  altered, 
and  I  remained  quiet  and  immovable.  Moreover,  the  same  voice  repeated  with- 
out ceasing,  'Move  and  you  will  be  dead.'  This  warning  was  the  cause  of  my 
immobility."  (Esquirol.)  See  also  the  well-known  case  of  the  French  prefect, 
by  the  same  observer. 

A  patient  (communication  by  Kieser,  *  Zeitschrift  fiir  Psychiatric,'  x.,  1853,  p. 
436)  describes  his  hallucinations  and  illusions  of  hearing  in  the  following  terms: 
— "  It  is  as  surprising  as  frightful,  and  to  me  degrading,  what  acoustic  practice 
and  experiments— and  without  reason— have  been  made  with  my  ear  and  my 
body  for  nearly  twenty  years!    I  had  the  shocking  conviction  that  not  only  with- 
out my  will,  but  even  without  my  knowledge,  sounds  and  articulate  words  of  the 
most  various  kinds  proceeded  from  my  ears  as  the  disgraceful  band  wished  it. 
And  such  sounds  and  words!    During  six  months  of  the  year  1815,  they  consisted 
almost  entirely  of  invectives  against  me  and  those  belonging  to  me;  one  and  the 
same  word  often  resounded  for  two  or  three  hours  without  interruption!    Then 
there  would  often  be  heard  a  long-continued  discourse  regarding  me,  generally 
containing  abuse;  the  voices  of  persons  well  known  to  me  were  often  imitated. 
These  discourses  rarely  contained  anything  that  was  true,  more  frequently  they 
contained  the  blackest  hes  and  calumnies  concerning  myself  and  others.     Fre- 
quently it  would  be  made  to  appear  that  it  was  I  who  said  all  that.     These  con- 
tinuous prolonged  sounds  were  often  heard  quite  near  to  me ;  frequently,  however, 
they  seemed  to  be  produced  half  or  even  a  whole  mile  off.     They  are  likewise 
thrown  and  violently  ejected  from  my  body:  the  greatest  noise  and  clatter  is 
heard  around  me,  especially  if  I  enter  a  house  or  go  into  a  village  or  town,  there- 
fore, I  have  for  several  years  lived  almost  like  a  hermit.     At  the  same  time,  my 
ears  almost  constantly  resound,  and  often  so  strongly  that  the  noise  may  be  heard 
at  a  considerable  distance.     Every  single  tree  when  I  approach  becomes— even  m 
calm  weather— a  source  of  murmurs  and  sounds  resembhng  words  and  speaking; 
the  carts  and  carriages  crack  and  sound  in  an  extraordinaiy  manner,  and  relate 
anecdotes;  the  horses'  hoofs  do  the  same;  the  swine  grunt  names  and  stories;  the 
dogs  bark  abuse  and  reproaches,  the  cocks  and  hens,  and  even  the  geese  and 
turkeys,  cackle  names,  words,  and  sentences.    The  smith  causes  his  hammer 
and  bellows  to  sound  words,  phrases,  and  often  entire  anecdotes,  and  thinks  he 
does  this  with  my  consent  and  will.     AU  who  come  near  me  tell  with  their  feet, 
without  their  will,  the  most  curious,  droll,  and  nonsensical  things  which  happen 
to  me  and  to  those  around  me.     This  is  especially  the  case  in  going  upstairs.  ^^  Even 
the  pen  with  which  I  write  produces  articulate  tones,  words,  and  phrases." 

At  other  times  the  patients  hear  celestial  harmony,  music  of  the 
spheres,  concerts;  frequently  accusations,  loose  speech,  and  indecent  lan- 
guage. Of  this  female  patients  often  bitterly  complain.  In  illusions  oi 
hearing,  sounds  present  are  transformed  in  the  sense  of  the  ruling  dis- 
position or  false  idea:  for  example,  a  noise  upon  the  steps  will  be  ascribed 
to  officers  of  the  law  coming  to  imprison  the  patient,  etc. ' 

There  is  a  particular  kind  of  hallucination  of  hearing  to  which  it  is 
difficult  to  give  a  name,  viz.,  those  internal  voices  without  sound,  mere 

>  In  Schiller's  '  Erwartung,'  simple  hallucinations  of  hearing  in  health  are  so 
described  that  they  may  be  taken  as  examples. 


THE    ELEIVIENTARY    DISORDERS    IN   MENTAL   DISEASE.  71 

lively  ideas,  which  appear  to  the  patient  as  speaking  and  answering. 
They  are  described  by  certain  of  the  insane  as  spiritual,  as  "the  voice  of 
the  soul,"  etc.  {mental  hallucination  of  Baillarger).  There  are  all  possi- 
ble varieties  of  them,  even  to  the  loudest  cry  of  voices. 

The  point  of  origin  of  these  morbid  phenomena  of  hearing  must  be  referred, 
in  part,  to  the  fourth  ventricle  and  its  neighborhood;  but  the  pathological 
anatomical  grounds  for  such  an  hypothesis  are  scanty. '  In  certain  cases,  phan- 
tasms of  hearing  could  be  stopped  by  stuffing  the  external  auditory  meatus.  At 
other  times  they  have  been  found  in  the  deaf. 

§  60.  Sense  of  smell. — Hallucinations  of  smell  are  not  so  common  as 
of  the  senses  we  have  just  considered:  they  appear  also  to  belong  chiefly 
to  the  early  stages  of  insanity.  Schlr<,ger^  found,  amongst  600  patients, 
27  cases  in  which  bad  smells  were  complained  of,  which  sometimes  caused 
ideas  of  poisoning,  with  refusal  of  food,  owing  to  the  idea  that  the  intes- 
tines were  putrefying.  In  the  great  majority  of  these  cases,  however,  the 
bad  smells  were  objective,  excited  from  without,  and  not  true  hallucina- 
tions; only  about  five  cases  could  be  considered  as  such.  In  almost  every 
case  it  is  disagi-eeable  odors  which  the  patients  perceive:  the  smell  of  sul- 
phur, of  carbonic  oxide,  of  carrion,  etc.  The  idea  of  living  in  a  poisoned 
atmosphere,  surrounded  by  dead  bodies,  etc. ,  is  a  frequent  result  of  these 
hallucinations.  Leuret  (loc.  cit.,  p.  198)  relates  the  case  of  a  woman  who 
ascribed  the  bad  smell  which  she  felt  to  the  effluvia  arising  from  mur- 
dered bodies  in  the  vaults  of  Salpetriere:  smells  presented  externally  were 
well  distinguished,  and  she  was  quite  normally  affected  by  them.  We 
have  seen  a  parallel  case  in  a  young  man. 

Sinogowitz  narrates  the  following  interesting  example  of  an  insanity 
which  depended  to  a  great  extent  on  illusions  of  smell. 

K — ,  formerly  lively  and  sociable,  became  gradually,  for  about  a  year,  medita- 
tive, taciturn,  irritable,  and  solitary;  he  often  used  secret  remedies,  and  always 
showed  distrust  of  those  by  vs^hom  he  was  surrounded.  At  last  he  openly  declared, 
"  I  feel  myself  very  unwell;  I  have  within  me  a  putrefying  mass  which  destroys 
my  inwards;  my  neighbors  therefore  treat  me  with  mockery  and  contempt,  and 
avoid  coming  near  me  because  I  emit  a  pestilential  odoi*."  He  led  a  solitary  and 
sorrowful  life;  his  delirium  became  always  more  confirmed,  and  he  accounted 
for  his  disease  by  infection  from  glanders.  He  removed  to  a  strange  town,  and 
took  a  walk  to  see  whether  those  whom  he  met  would  also  avoid  him  on  account 
of  the  bad  smell.  As,  by  chance,  a  passer-by  put  his  pocket-handkerchief  to  his 
nose,  and  at  the  same  time  looked  at  him,  K —  violently  attacked  him,  called  him 
a  hard-hearted  mocker,  an  uncharitable  despiser  of  men,  and  gave  him  a  box  on 
the  ear.  He  was  then  recognized  to  be  insane;  it  was  found  that  he  was  insensi- 
ble to  external  odors;  he  declared  that  he  felt  only  his  own  smell,  which  resembled 
that  of  horse's  urine,  and  complained  also  of  a  corresponding  taste  in  his  mouth. 
The  patient  then  gave  himself  to  onanism;  he  soon  began  to  complain  of  con- 
stant dull  pain  in  the  head,  to  grow  lean,  and  at  last  fell  into  dementia. 

In  a  patient  who  had  strong  hallucinations  of  smell,  a  fungus  of  the  dura 
mater  as  large  as  a  hazel-nut  was  found  in  the  cribriform  process,  and  surrounded 
by  the  olfactory  nerves  ('Vienna  Asylum  report,'  1858,  p.  266). 

In  another  patient,  who  had  been  constantly  followed  for  more  than  six 
months  by  a  smell  of  dead  bodies,  there  was  found  an  abscess  of  the  corpus  callo- 
sum  (Cabanis,  quoted  by  Morel.  'Traite  des  Maladies  mentales,'  p  331).  The 
island  of  Reil  might,  according  to  certain  facts  in  the  minute  anatomy  of  the 
brain,  be  considered  an  olfactory  centre. 

Hallucinations  of  taste. — In  this  sense  real  hallucinations  cannot  be 

^  Foville  says  that  he  has  found  adhesions  of  the  surface  of  the  cerebellum  to 
the  membranes.  But  there  appears  to  be  also  a  prolongation  of  the  auditory 
nerves  into  the  great  hemispheres. 

^  'Zeitschrift  der  k.  k.  Gesellschaft  zu  Wien,'  1858,  19,  20. 


72  THE    ELEMENTARY    DISORDERS    tN    MENTAL    DISEASE. 

distinguished  from  illusions,  false  interpretation  of  real  objective  impres- 
sions (from  furred  tongue,  state  of  the  saliva,  etc.)-  Here,  too,  there  are 
commonly  disagreeable  sensations  of  taste  of  which  thejiatients  complain: 
they  say  that  everything  has  a  bad  taste,  metallic,  sharp,  rotten,  sandy, 
earthy,  etc. ;  and  found  on  this  the  idea  of  poisoning,  hate  towards  their 
neighbors,  and  frequently  refusal  of  food — always  so  important  on  ac- 
count of  its  speedy  and  injurious  influence  on  the  organism.  The  cases 
in  which  the  insane  have  agreeable  sensations  of  taste — suppose  that  they 
eat  delicacies — are  very  rare. 

Esquirol  mentions  such  cases,  the  single  case  brought  forward  by  Leuret 
(p.  197)  can  scarcely  be  considered  an  example  of  this. 

§  61.  In  the  skin,  and  in  the  viscera,  hallucinations  and  illusions  can- 
not be  distinguished  from  each  other  ;  or  rather  the  phenomena  which 
constitute  them,  so  far  as  they  do  not  depend  on  anassthesia  (§  49),  are  in 
every  case  to  be  considered  as  illusions,  because  the  specific  anomaly 
consists  in  the  false  interpretation  of  certain  sensations  observed  in 
health  or  in  various  states  of  disease.  The  commencement  of  these  illu- 
sions consists  in  certain  painful  sensations  being  merely  phantastically 
compared  by  the  patient  to  analogous  phenomena.  Therefore  hypochon- 
driacs, at  first,  say  only  that  it  seems  to  them  as  if  serpents  crawled  in 
their  skin,  as  if  there  were  frogs  in  their  belly,  as  if  a  bird  chirped  with- 
in their  chest,  or,  as  we  once  heard  a  patient  say,  a  young  dog  lapped 
water  in  their  head.  But,  by  prolongation  of  the  sensations,  the  influ- 
ence of  unfavorable  external  circumstances,  and  increasing  internal  dis- 
harmony, owing  to  which  the  patient  soon  begins  to  consider  the  matter 
more  earnestly,  the  comparison,  at  first  imaginary,  becomes  a  fully  de- 
veloped delirium:  then,  from  abnormal  cutaneous  sensations  or  morbid 
muscular  action,  there  originate  fixed  ideas,  in  which  those  sensations  are 
seriously  attributed  either  to  internal  phantastic  causes  (spiders,  crickets, 
and  other  animals  in  the  body,  demoniacal  possession  of  certain  organs), 
or  to  outward  influences  of  a  prejudicial  kind  (magnetism,  physical  ex- 
periments). Thus,  the  idea  of  being  stabbed  or  flogged,  of  the  arms 
being  bound  or  made  fast,  is  seen  to  originate  from  certain  pains  in  the 
skin;  and  from  abnormal  abdominal  sensations,  the  idea  that  the  devil,  the 
last  judgment,  crucifixion,'  is  taking  place  within  the  belly  of  the  patient. 
Any  part  of  the  body  may  become  the  point  of  origin  of  such  insane 
ideas.  A  young  man  told  me  he  had  felt  the  devil,  rough  and  bristly, 
seize  him  by  the  neck  (globus  hystericus?);  another,  mentioned tiy  Sinogo- 
witz,  stufled  his  nose  at  night  because  venomous  worms  crawled  into  it. 
A  woman,  spoken  of  by  Bergmann,  saw  in  her  breast  a  circular  fiery  body 
turning  constantly  round. 

The  sexual  illusions  merit  special  consideration,  as,  from  normal  and 
abnormal  sexual  sensations,  there  is  frequently  developed  in  men  the  idea 
that  they  are  urged  by  others  to  onanism;  in  women,  the  idea  of  preg- 
nancy, of  their  accouchement  always  being  imminent — of  sexual  inter- 
course with  some  imaginary  lover,  with  the  devil,  etc. ;  and  as  those 
sensations  constitute  a  frequent  source  of  sexual  insanity  which  may 
show  itself  in  the  form  of  sentimentality,  or  of  nymphomania. 

^  A  patient  of  Esquirol's  had  this  delusion.  "  I  can  scarcely  bear  it,"  he  said 
occasionally :  ' '  when  will  there  be  lasting  peace  in  the  Church  ?  "  A  patient  in 
Winnenthal  cried  continuously,  for  months,  "  Desist,  and  let  me  go! "  He  some- 
times believed  that  he  was  tormented  by  something  within  Ixis  body,  sometimes 
that  he  was  stmck  with  the  horns  of  imaginary  oxen. 


THE    ELEMENTARY    DISOKDERS    IN    MENTAL    DISEASE.  73 

Hallucinations  and  illusions  of  several  senses  combined  are  very 
common,  and  the  literature  of  this  subject  (Hagen,  Escjuirol,  Leuret, 
Bottex)  is  rich  in  examples  in  which  simultaneous  false  perceptions  of  all 
the  senses  formed  the  most  important  and  most  striking  phenomena  of 
the  insanity.  In  a  practical  point  of  view,  it  cannot  be  too  much  insisted 
on  that  these  false  perceptions  of  the  senses  be  sufficiently  investigated, 
that  they  are  often  results  of  organic  processes  which  may  be  allayed, 
and  that  attention  be  paid  to  these  in  considering  the  plan  of  treatment. 
In  relation  to  this,  we  might  recommend — a  point  hitherto  quite  over- 
looked in  hallucinations  of  the  three  superior  senses — attention  to  the 
state  of  their  accessory  nerves,  the  fifth  pair:  in  several  cases,  hallucina- 
tions of  hearing  and  of  sight  appeared  to  us  to  have  been  awakened  by 
neuralgic  affections  of  these  nerves. 

I  saw,  now  many  years  ago,  a  remarkable  case  which  began  with  hallucina- 
tions of  several  senses.  A  man  was  returning  one  moonlight  night  from  a  pedes- 
trian excursion  by  which  he  was  somewhat  fatigued.  All  at  once  it  seemed  to 
him  as  if  he  saw  a  great  animal  like  a  dragon  rolling  i^-self  in  a  ditch  filled  witli 
water  by  the  roadside.  He  became  exceedingly  af raia,  and  at  the  same  time  f e]  t 
himself  painfully  grasped  on  the  right  shoulder  by  the  animal;  nevertheless,  he 
could,  as  he  said,  free  himself  by  running.  Immediately  after,  he  fell  into  a 
disease  which  was  soon  discovered  to  be  a  pleural  exudation  of  the  right  side, 
filling  the  whole  of  that  side  of  the  chest.  He  died  in  a  few  months,  and  I  was 
present  at  the  examination  of  the  body. 

SECTioiir  III. — The  Elementarij  Disorders  of  Moveinent. 

§  62.  We  observe,  in  most  of  the  insane,  slight  inconsiderable  dis- 
orders of  muscular  movement;  changes  in  the  tone  of  voice;  slowness  or 
excessive  rapidity  of  the  contraction  of  the  muscles,  etc.  It  is  not  rare 
to  see  also  a  certain  degree  of  general  tightness  and  rigidity,  or  of  relax- 
ation of  the  muscles  ;  the  latter  principally  in  states  of  weakness. 
Difficulty  of  movement  of  the  whole  body,  including  the  organs  of 
speech,  perhaps  even  statue-like  cataleptic  rigidity,  is  proper,  in  particu- 
lar, to  the  so-called  ecstatic  states  (see  §  51),  in  which  the  external 
sensorial  activity  is  at  the  same  time  more  or  less  suspended  (generally 
with  coexisting  hallucinations),  and  the  patient  is  plunged  either  in 
inexpressible  mystical  joy,  in  ecstasies,  or  in  a  state  of  violent  painful 
emotion.  Such  muscular  rigidity,  moderate  and  of  short  duration,  may 
be  present  in  the  slightest,  most  curable,  forms  of  insanity,  and  does  not 
render  the  prognosis  less  hopeful ;  yet,  in  certain  cases,  the  patients 
have  become  demented  (Guislain).  Of  far  greater  significance  are,  on  the 
one  hand,  the  local  contractions  interrupted  at  times  by  paralysis,  and  on 
the  other,  the  partial  or  general  convulsive  states.  The  persistent 
automatic  grimacing,  strabismus  originating  during  the  disease— immod- 
erate contraction,  dilatation,  and  irregularity  of  the  pupils — painful  con- 
vulsions of  the  muscles  of  the  neck — those  confused  convulsive  move- 
ments of  the  extremities  which  cause  the  patient  often  to  walk  irregularly, 
or  to  progress  in  short  leaps — are  all  phenomena  of  serious  signification, 
and  their  continuance  usually  indicates  a  transition  to  the  state  of  in- 
curability. A  constant  trembling,  grinding  of  the  teeth,  chorea-like 
symptoms  in  adult  lunatics,  automatic  circular  movements,  walking 
backwards,  are  likewise,  at  least  in  the  majority  of  cases,  symptoms  of 
the  development  of  serious  organic  disease  of  the  brain:  although,  in 
accordance  with  certain  observations  of  subsequent  recovery  in  similar 
cases,  we  must  admit  the  possibility  of  the  production  of  the  phenomena 
from  simple  nervous  irritation,  or  from  temporary  palpable  disease.    The 


74:  THE   ELEMENTARY    DISOKDERS    IN    MENTAL    DISEASE. 

gravest,  and,  alas!  but  too  frequent,  anomalies  of  movement  in  the 
insane,  are,  however,  the  epileptic  and  general  paralytic  states,  to  which 
we  shall,  owing  to  their  great  importance,  devote  a  special  chapter  (see 
the  Complications  of  Insanity.) 

In  cases  of  obstinate  taciturnity,  which  sometimes  continues  for  several — 
certain  cases  for  ten  years,  and  even  longer — we  must,  first  of  all,  discover 
whether  the  patient  ivill  not  speak  (simple  morbid  peculiarity)  or  cannot  speak 
(chronic  cataleptic  states,  profound  melancholia,  stupor,  dementia).  The  strength 
and  tone  of  the  voice  correspond  in  general  to  the  ruling  disposition  of  mind. 

In  the  insane  there  is  sometimes  observed  a  convulsive  rolling  of  the  eyeball 
(nystagmus).  This  phenomenon  appeai-s  to  belong  to  the  period  of  transition  from 
the  acute  into  the  chronic  states,  and  is  therefore  of  unfavorable  prognosis. 
Modifications  in  the  mobility  of  the  iris  are  more  common.  Inequality  of  the 
pupils  is  seen  most  frequently  in  paralytic  dementia,  more  seldom  in  simple  cases 
of  mania  or  melancholia:  and  hei-e  also  it  is  most  common  in  chronic,  slowly 
progressing,  and  hopeless  cases.  In  certain  cases  the  inequality  appears  for  the 
first  time  during  convalescence.  Great  contraction  of  the  pupils  in  mania  is, 
according  to  experience,  of  unfavorable  prognosis,  and  I'enders  probable  the  com- 
mencement of  paralytic  dementia.  In  insanity,  as  in  many  other  affections  of 
the  brain  and  nerves,  it  cannot  in  every  case  be  ascertained  whether  the  abnormal 
state  of  the  pupils  depends  on  convulsion  or  paralysis  ;  but  the  latter,  from  the 
symptoms,  appears  generally  to  be  the  more  probable.  See  Merier,  '  Gazette  des 
Hopitaux,'  1853,  19  Aout ;  Seifert,  'Zeitschrift  fiir  Psychiatric,'  x.,  1853,  p.  544  ; 
Richarz,  ibid.,  xv.,  1858,  p.  21. 


ON    INSANITY    IN   GENERAL.  .  75 


CHAPTER    V. 
ON  INSANITY  IN  GENERAL. 

Section  I. — The  Analogies  of  Insanity. 

§  63.  What  may  be  said  on  insanity  in  general,  its  course,  its  mode 
of  termination,  etc. ,  can  only  be  drawn  from  the  study  of  its  single  forms, 
owing  to  the  extraordinary  diversities  which  they  present.  Still,  our 
general  knowledge  of  mental  diseases  is  considerably  increased  by  consider- 
ing their  analogy  to  certain  kindred  states,  especially  to  dreams  and  to 
the  delirium  of  fever. ' 

The  simple  testimony,  so  frequently  given  by  those  who  have  recov- 
ered, that  the  whole  period  of  their  disease  now  appears  to  them  as  a 
dream — sometimes  a  happy,  but  more  frequently  a  painful  and  gloomy 
one;  and  further,  that  during  insanity,  in  certain  cases,  the  impression 
left  by  their  former  healthy  life  was  also  like  a  bygone  dream — might 
lead  us  to  the  great  similarity  of  insanity  to  states  of  dreaming. 

It  is  true  that  in  the  insane  the  principal  signs  of  sleep  are  absent — 
the  closing  of  the  external  senses,  the  suppression  of  consciousness  of  the 
outer  world,  and  of  the  influence  of  the  will  upon  the  muscles — all  of 
which  we  regard  as  essential  to  dreaming.  But,  on  the  one  hand,  it  is 
known  that  we  dream  the  more  readily  the  less  profound  our  sleep  is, 
and  that  there  are  states  of  sleep  where  an  influence  similar,  indeed 
almost  akin,  to  a  waking  state  is  exerted  on  the  muscles  (speaking  dur- 
ing sleep,  sleeping  of  the  postilion  while  riding,  somnambulism).  On 
the  other  hand,  the  whole  circle  of  such  sensorial  acts  as  do  not  originate 
through  external  excitation  of  the  senses,  and  which  nevertheless  may 
exert  such  power  (which  acts  exert  such  influence  in  mental  diseases), 
can  be  considered  as  related  to  dreaming  in  the  wider  sense.  Finally, 
there  are  in  the  insane  states  of  sensation  and  of  motion, — dulness  of  sen- 
sorial impressions,  which  no  longer  aflect  (§  50)  the  individual  as  they 
formerly  did — that  weakening  of  the  influence  of  the  will  upon  the  mus- 
cles which  is  manifested  in  great  slowness  of  movement,  and  even,  at 
times,  in  cataleptic  persistence  of  positions  enforced  (§  62), — which,  in 
connection  with  the  coexistent  obscurity  of  consciousness,  vividly  reminds 
us  of  what  takes  place  when  sleep  comes  on. 

Indeed,  the  analogy  of  insanity  to  dreaming,  especially  to  dreams  occurring 
in  the  half-waking  state,  must  be  admitted.  In  children,  we  occasionally  see, 
especially  when  under  slight  disease,  that  they,  while  sleeping,  still  speak;  for 
example,  they  understand  the  mother,  they  answer  her,  they  open  their  eyes  and 
recognize  her,  but  nevertheless  they  dream  on,  and  in  particular  they  cannot 
withdraw  themselves  from  uneasy  dreamy  ideas.  Even  the  intermediate  con- 
ditions of  sleep  and  waking,  which  succeed  each  other  in  endless  gradations, 

'  The  analogy  of  insanity  to  the  emotional  states  of  health  has  already  been 
spoken  of ;  the  similarity  of  many  states  of  mental  disease  to  intoxication  will  be 
afterwards  mentioned  (under  Mania  and  General  Paralysis). 


76  OK    INSANITY    IN    GENERAL. 

strongly  favor  the  appearance  of  illusions  and  hallucinations  (§  56),  and  which 
are  distinguished  by  an  irregular  activity  of  the  imagination  and  by  incoherence 
of  the  intelligence.  They  are  preceded  by  a  state  of  sleepiness,  the  individual 
being  dull,  torpid,  and  taciturn;  the  senses  become  blunt,  the  impressions  of 
sight  fail,  sounds  appear  distant,  his  consciousness  is  dull,  answers  are  delayed, 
he  forgets  himself  and  speaks  incoherently.  These  are  often  observed  in  the 
commencement  of  insanity.  In  the  first  place,  sensitive  and  motory  reaction 
towards  the  external  world  becomes  feeble;  and  secondly,  a  world  of  phantasms 
and  confused  ideas  appears,  in  which  the  patient  loses  liimself.  This  gradual 
lulling  of  the  understanding  and  will,  wliich  constitutes  healthy  sleep,  is  denied 
the  insane  man,  owing  to  the  pei-sistent  (painful)  emotions;  and  we  often  observe 
also,  in  the  commencing  period  of  the  disease,  in  spite  of  the  apparent  sleepy 
tiredness,  actual  sleeplessness. 

Bichat  says,  "  Le  sommeil  general  est  I'ensemble  des  sommeils  particuliers;" 
indeed,  each  sense  and  each  phase  of  mental  life  may  be  at  the  same  time  awake 
in  different  degrees,  the  one  more  than  the  other.  In  somnambulists  certain 
faculties  are  very  active,  and  dreams  set  in  action  may,  if  of  short  duration,  be 
considered  as  somnambulism;  if  of  longer  continuance,  as  mental  disorder. 

§  64.  The  dream,  like  insanity,  receives  its  essential  color,  its  certain 
iundamental  tone,  from  the  governing  disposition;  Avhicli  may  be  deter- 
mined as  well  by  the  mental  occurrences  of  waking  life,  as  by  changes  of 
the  organic  states  during  sleep;  in  which,  especially,  all  congestive  states, 
and  all  morbid  impressions  from  the  digestive  organs,  and  abdominal 
organs  in  general,  have  a  very  great  influence.  The  ruling  sentiments 
of  pleasure  and  pain  call  for  their  corresponding  images,  in  which  objects 
without  form  in  themselves,  become  sensuous  clothed  forms,  the  reality  of 
the  actual  impression  is  delusive,  and  what  enters  from  without,  through 
the  senses,  meets  in  the  dreamer,  as  in  the  insane  man,  a  centre,  pre- 
occupied and  filled  with  the  given  disposition,  and  becomes  perverted 
and  construed  in  the  sense  of  the  ruling  sentiments  and  ideas.  On  the 
other  hand,  however,  the  same  twofoldness  of  the  personality  and  the 
.same  emotions  ensue  when  groups  of  ideas  and  sentiments  of  unaccus- 
tomed hostile  intent  stand  opposed  to  the/,  and  the  dream,  like  insanity, 
is  busy  to  transfer  to  the  external  world  and  to  dramatize  subjective 
images  (hallucinations)  of  all  the  senses. 

In  dreaming,  this  occurs  particularly  with  bodily  sensations,  in  the  elaboration 
of  which  there  is  great  exaggeration  and  they  have  a  powerful  effect  upon  the 
imagination.  A  confined  position  in  bed,  pressure  on  the  arm  or  the  breast, 
becomes  cause  of  sensations  of  being  put  in  chains,  of  danger,  of  precipices,  of 
threatened  execution,  etc. ;  a  draught  of  air  coming  on  us  excites  ideas  of  being 
at  sea,  and  the  other  circumstances  connected  with  it;  warmth  of  the  feet  causes 
us  to  dream  of  fatiguing  marches,  or  of  climbing  a  burning  mountain;  a  slight 
prick  evokes  ideas  of  drawn  swords;  bodily  feelings  of  anxiety  from  oppressed 
respiration  may  excite  the  idea  of  a  monster  setting  on  us,  or  dramatic  represen- 
tations of  great  crimes  being  committed,  against  all  of  which,  however,  our 
natural  I,  to  which  no  such  thoughts  belong,  strongly  protests.  All  these  closely 
resemble  the  waking  dreams  of  the  melancholic,  and  in  both  conditions  the 
individual  cannot  recognize  these  false  representations  as  such  for  want  of  reflec- 
tion, owing  to  repression  of  the  I  or  even  partial  overthrow  of  it,  and  because 
rectification  through  the  senses  is  impossible,  in  the  one  case  through  their  dul- 
ness,  and  in  the  other  through  their  false  images  (hallucinations).  Heerman 
narrates  that  when  asleep,  having  colic  pains,  he  dreamed  that  his  belly  was 
opened  and  that  a  preparation  was  made  of  his  sympathetic  nerve.  _  We  have 
brought  forward  examples  (§  61)  of  similar  interpretations  of  abnormal  sensations 
by  the  insane  when  awake. 

The  dreamer,  like  the  insane,  accepts  all,  even  the  most  adventurous  and 
foolish,  representations  as  possibilities  without  particular  astonishment,  and  the 
veriest  absurdity  becomes  the  most  unquestionable  truth,  if  the  naasses  of  percep- 
tions which  can  rectify  it  remain  dormant.  An  individual  may  dream  of  having 
solved  a  scientific  problem,  and  is  filled  with  joy  at  his  fortunate  success;  he 
awakes  and  discovers  that  it  is  an  ordinary  false  thought.    Thus,  there  are  insane 


ON    INSANITY    IN    GENERAL.  77 

persons  who  suddenly  discover  perpetual  motion,  or  a  mechanicnl  idea  which, 
must  change  the  whole  surface  of  the  earth,  and  similar  tilings:  they  circ  filled 
with  ecstasy  at  such  discoveries;  what  they  demonstrate,  hov'over,  ic  to  ue  folly, 
and  they,  after  removery,  cannot  understand  why  they  could  not  at  once  see 
through  such  great  errors. 

§  65.  Agreeable,  ravishing,  heavenly  dreams  are  very  rare  in  health  r 
they  are  most  frequent  in  states  of  deep  bodily  or  mental  exhaustion,  and 
Ave  often  observe  at  such  times  tliat  the  ideas  suppressed  during  waking 
come  forth  strongly  in  dreams.  To  the  individual  who  is  distressed  by 
bodily  and  mental  troubles,  the  dream  realizes  what  reality  has  refused — 
happiness  and  fortune.  The  starving  Trenck,  during  his  imprisonment, 
often  dreamed  of  rich  repasts;  the  beggar  dreams  that  he  is  wealthy,  the 
person  who  has  lost  by  death  some  dear  friend  fondly  dreams  of  the  most 
ultimate  and  lasting  reunion.  So  also  in  mental  disease,  from  the  dark 
background  of  morbid  painful  emotion,  by  sinking  into  a  still  deeper 
state  of  dreaming,  the  repressed  contending  ideas  and  sentiments — bright 
ideas  of  fortune,  greatness,  eminence,  riches,  etc.,  stand  out — and,  as 
soon  as  this  happens,  through  a  change  in  the  state  of  the  brain,  but 
without  recovery,  the  pressure  of  the  painful  sensations  is  removed,  the 
former  mental  misery  changes  voluntarily  to  the  mirth  of  the  maniac. 
Thus  we  see  clearly  how  supposed  possession  and  imaginary  realization  of 
good  things  and  wishes,  the  denial  or  destruction  of  which  furnished  a 
moral  cause  of  the  disease,  constitute  commonly  the  chief  subjects  of  the 
delirium  of  insanity;  for  example,  she  who  has  lost  a  darling  child  raves 
of  a  mother's  joy,  he  who  has  suffered  loss  of  fortune  imagines  himself 
rich,  the  disappointed  maiden  is  hajjpy  in  the  thought  that  she  is  tenderly 
loved  by  a  faithful  lover. 

A  number  of  other  phenomena  of  dreaming  present  an  evident  analogy  ta 
insanity.  Thus,  sometimes  in  insanity,  as  in  dreams,  all  idea  of  time  is  wanting;, 
minutes  seem  hours,  as  in  a  dream  we  live  years  in  a  quarter  of  an  hour,  and 
events  which  would  take  months  to  occur  in  reality,  appear  to  the  insane  man 
to  pass  in  the  shortest  space  of  time.  In  both  states,  muscular  sensations — inter- 
preted as  flying,  being  precipitated,  etc. — and  illusions  play  a  most  iniportant 
part,  and  the  latter  serve,  in  particular,  to  express  certain  situations  evoked  by  a 
governing  fundamental  disposition  and  cori-esponding  to  it,  while  the  masses  of 
perceptions  of  the  I,  which  could  bring  order  into  this  chaos,  are  partly  obliterated 
or  destroyed,  partly  lie  in  painful  opposition  to  the  new  contents  of  the  mental 
life,  or  are  violently  carried  by  this  in  certain  definite  directions. 

Those  rarer  cases  are  very  interesting  where  intermitting  insanity  takes  the- 
place  of  normal  sleep,  and  thereby  seems  to  stand  midway  between  dreaming  and 
somnambulism.  Guislain  ('  Die  Phrenopathieen,'  translated  by  Wunderlich,  p.  80) 
relates  such  a  case,  and  considers  generally  that  there  exists  a  certain  analogy 
between  mental  disease  and  states  of  dreaming.  Those  cases  also  are  of  the  same 
nature  in  which  a  state  of  waking  dream  suddenly  interrupts  the  ordinary  state 
of  waking,  which  after  its  cessation  again  assumes  its  ordinary  course.  A  lady 
was  subject  to  such  paroxysms:  suddenly  in  the  midst  of  a  conrersation  she 
would  stop  and  commence  to  speak  of  something  else;  after  a  certain  time,  she 
would  again  resume  the  conversation  at  the  sentence  and  word  at  which  she  had 
bi'oken  off,  and  be  quite  unconscious  of  the  interruption.  A  lady  from  New  York 
suddenly  became  delirious  while  working  some  intricate  embroidery;  she 
remained  ill  for  seven  years,  and  as  suddenly  recovered.  She  immediately 
resumed  her  work  with  the  same  composure  as  if  she  had  only  been  an  hour 
absent  from  it  (Prichard,  '  Annal.  Medicopsychol.,'  i.,  1843,  p.  336). 

When  the  seeds  of  mental  disease  are  actually  present,  agitating  dreams  may 
hasten  its  outbreak;  sometimes  the  subject  of  the  future  delirium  is  clearly 
exhibited  in  them.  Results  of  the  existing  cerebral  in-itation,  they  act  destruc- 
tively on  the  emotions,  and  their  after-effects  continue  dominant  during  the 
waking  state. 

§  66.  Many  states  of  insanity  specially  resemble  the  so-called  magnetic 


78  ON    INSANITY    IN    GENERAL. 

sleep  which  is  observed  in  chronic  nervous  diseases,  particularly  in  states 
of  serious  constitutional  disturbance.  The  extraordinary  feeling  of  well- 
being  in  its  higher  grades,  those  indescribable  sensations  which  seem  to 
belong  to  another  sphere,  are  here  exhibited  in  the  great  satisfaction  and 
contentment  seen  in  many  maniacal  states,  and  in  those  feelings  of  exqui- 
site happiness  experienced  by  many  of  the  insane  which  really  cannot  be 
described,  and  for  which  they  themselves  choose  the  image  of  the  divine. 
The  new  expressions  which  certain  somnambulists  suppose  to  be  the  com- 
mon language  of  the  region  of  the  spirits — that  tendency  to  busy  them- 
selves mystically  with  the  construction  of  the  universe,  and,  above  all, 
with  the  highest  problems  of  human  thought,  and  that  affectation  of  fine 
language  in  those  without  education,  are  all  to  be  found,  alike  combined, 
in  many  chronic  maniacs;  and  in  certain  cases  the  greater  freedom  of  the 
organs  of  movement  in  the  latter  state  constitutes  the  chief  distinction. 

It  appears  also  that  magnetic  exaltation,  like  maniacal  agitation,  is  frequently 
developed  from  anterior  states  of  pain,  and  that  there  then  results  antagonistic 
dominion,  on  the  one  hand,  of  the  bodily  and  mental  affection  during  waking, 
and  on  the  other,  according  to  our  observation,  of  obscure  states  of  dreaming 
accompanied  by  nightmare,  which  constitute  the  first  period  of  the  magnetic  state. 
The  further  confirmation  of  the  latter  conditions  would  be  very  important  for 
the  analogy  in  the  course  of  both  series  of  morbid  states.  In  the  somnambulists, 
also,  their  knowledge— according  to  all  experience  so  very  worthless  -is  generally 
communicated  through  the  medium  of  hallucinations  (of  sight  and  hearing). 
Most  of  the  analogies  mentioned  in  the  preceding  paragraphs  with  the  other 
states  of  dreaming  serve  also  for  the  magnetic  states;  and,  particularly,  reminis- 
cences of  magnetic  dreams  are  not  so  rare  as  is  generally  supposed. 

Although  the  different  states  of  insanity  do  not  in  the  same  degree  possess  the 
character  of  dreams— although  this  attaches  most  to  certain  primary  forms, 
especially  to  melanchoha  with  stupor,  in  which,  indeed,  intercourse  with  the 
external  word  is  extremely  limited,  and  impressions  are  phantastically  trans- 
formed, and  also  to  certain  states  of  mania;  although,  on  the  contrary,  other 
particvdarly  secondary,  forms,  such  as  partial  dementia,  present  all  the  signs  of 
complete  waking,  in  which  at  times  the  patient  renounces  his  whole  former  iife 
or  has  quite  forgotten  it — where  he  lives,  externally  in  the  false  world  of  his 
hallucinations,  and  internally  in  the  reveries  of  his  false  ideas:— whether  such 
waking,  indeed,  is  not  more  analogous  to  certain  magnetic  states  which  partially 
conceal  our  day-hf e,  than  to  that  waking  which  we  know  by  experience  to  be 
the  healthy  state. 

The  analogy  of  mental  disease  to  dreams  has  in  recent  times  been  treated  ot 
by  several  authors,  especially  by  Moreau,  '  Annal.  Med.  Psych.,'  1855,  p.  11,  ff.; 
ibid.,  p.  361;  Maury,  ibid.,  1853,  v.,  p.  40-4;  Holland,  'Chapters  on  Mental  Phy- 
siology,' 2d  edition. 

§  67.  As,  however,  insanity  presents  a  similarity  sometimes  superficial, 
sometimes  profound,  sometimes  qualitative  to  the  various  states  of  dream- 
ing; so  the  psychical  process  by  means  of  which  the  individual,  when  the 
cerebral  disease  is  removed,  returns  to  healthy  life,  presents  various  modi- 
fications. Sometimes  recovery  resembles  simple  waking;  when  the  indi- 
vidual astonished  seeks,  as  it  were,  to  know  himself,  the  masses  of  ideas 
belonging  to  the  disease  soon  disappear,  and  the  old  /returns  uninjured 
and  unimpaired  to  its  former  place.  At  other  times,  the  already  united 
connections  loose  themselves  with  greater  difficulty,  and  as  the  old  / 
is  but  slowly  strengthened,  recovery  consists  again  of  a  painful  struggle, 
in  which  the  individual  awakened  frequently  requires  the  instruction 
and  advice  of  another  will  to  strengthen  his.  Not  unfrequently,  even 
then  all  the  traces  of  the  morbid  state  do  not  disappear,  and  the  patient 
for  a  long  time  retains,  as  vestiges  of  the  past,  certain  ties,  oddities, 
aberrations,  and  perversions.  From  this  point  it  may  frequently  be  ob- 
served that  the  patient  undergoes  a  decided  change  of  character. 


ON    INSANITY    IN    GENERAL.  79 

It  is  inadmissible  to  refer  those  processes  to  the  moral  sphere,  to  which  they  as 
little  belong  as  the  process  which  characterizes  the  commencement  of  the  disease; 
but  it  is  certain  that,  for  a  convalescent  who  has  been  formerly  unsteady,  proper 
moral  training  is  necessary,  and  that  very  often  the  physician  may  produce  a  new 
effect  on  the  patient  by  such  instruction  as  is  generally  given  to  the  young. 

Those  cases  are  very  interesting  where,  shortly  before  death,  the  men- 
tal health  completely  returns  or  becomes  decidedly  improved.  This 
occurs  most  frequently  in  mania,'  seldom  in  melancholia,  and  almost 
never  in  the  secondary  forms — chronic  mania  and  dementia.  In  those 
cases  where  serious  anatomical  changes  have  already  taken  place  in  the 
brain,  and  the  morbid  perceptions  have  completely  pervaded  and  destroyed 
the  /,  the  fundamental  requisites  of  return  to  normal  thought  seem  to  be 
wanting.     The  length  of  time  required  for  this  cannot  be  estimated. 

Brierre  de  Boismont-  mentions  the  case  of  a  gardener  who,  in  his  twenty- 
second  year,  after  receiving  a  violent  fright  from  a  person  dressed  like  a  bear,  at 
a  masked  ball,  became  insane,  and  for  fifty-two  j'ears  did  not  speak  a  word,  but 
appeared,  with  growls  and  moving  to-and-fro  of  the  body,  to  imitate  that  species 
of  animal.  Some  weeks  before  his  death,  when  diarrhoea  and  oedema  had  set  in, 
he  began  to  speak;  his  intelligence  showed  itself  to  be,  indeed,  very  limited,  but 
the  connection  of  his  thoughts  was  correct  and  orderly. 

In  cases  where  the  cerebral  symptoms  originate  secondarily,  and  are  main- 
tained by  disease  in  other  organs,  and  still  depend  on  simple  nervous  irritation 
or  on  slight  hyperasmia,  such  mental  improvement  before  death  may  even  be 
expected;  this  is  easily  explained,  and  is  in  many  ways  analogous  to  the  cessa- 
tion of  certain  pains  before  death.  Certain  exceedingly  rare  cases  have  also  been 
seen  where  even  dements  (paralytic)  some  time  before  death  recovered  a  great 
part  of  their  lost  recollections,  and  exhibited  a  certain  correctness  of  judgment. 
Such,  it  is  true,  is  still  far  from  being  a  state  of  reason.  Hoffmann  correctly 
remarks,  that  this  "  rationality  "  which  reappears  shortly  before  death  is  in  most 
cases  merely  a  re-establishing  of  an  equilibrium  between  diminished  powers,  the 
past,  the  future,  and  the  most  important  relations  of  life  still  remaining  in 
obscurity. 

Such  mental  improvement  before  death  is  not  always  coincident  with  marked 
aggravation  of  the  bodily  symptoms;  cases  have  occurred  where  the  patients 
were  considered  cured,  and  then  rapidly  carried  off  by  sudden  death.  It  is  very 
rare  to  see  insanity  assume  a  more  serious  form  shortly  before  death,  still,  in 
mania,  an  access  of  fury  sometimes  comes  on  which  does  not  cease  tiU  death 
occurs. 

§  68.  The  acute  delirium  of  fever,  from  which  insanity  is  in  no  way 
specifically  distinct,  likewise  consists  of  active  dreams  during  waking  or 
half- waking.  Although  generally  the  delirium  of  fever  is  more  a  state 
of  simple  incoherence  than  of  mental  aberration,  still  we  observe  fre- 
quently that  in  these  dreams  the  various  hallucinations  and  false  ideas 
are  only  expressions  of  a  governing  fundamental  disposition,  sometimes 
fixed,  sometimes  changing,  and  are  thus  connected  through  the  unity  of 
the  ruling  sentiments;  and  also  that  the  specid  subject  of  each  of  the 
imaginary  images  and  false  ideas  is  generally  decided  by  accidental  cir- 
cumstances (psychical  wants,  the  paper  on  the  wall,  old  recollections). 
In  the  delirium  of  fever  also,  we  can  often  arrive  at  the  same  fundamen- 
tal psychical  differences  according  to  which  the  division  of  mental  diseases 
into  single  principal  forms  is  based.  Thus  there  is  a  melancholia,  a 
mania,  partial  dementia  (restricted  to  single  insane  ideas  without  much 
emotion),  and  dementia  in  febrile  delirium.     There  are  also  certain  pre- 

1  In  the  Quaker  Asylum  at  York,  in  33  cases  of  death  from  mania  this  occurred 
8  times,  and  in  45  from  melancholia  8  times  (Julius,  '  Contributions  to  British 
Mental  Medicine,'  p.  255).  The  three  examples  brought  forward  by  Parchappe 
were  also  cases  of  mania. 

2  '  Gazette  des  Hopitaux,'  1844,  No.  54. 


80  ON    INSANITY    IN    GENEBAL. 

disposing  constitutional  causes  of  slight  delirium  as  of  mental  disease,  such, 
as  previous  weakness,  hereditary  influences,  etc. 

Although,  in  general,  acute  delirium  differs  essentially  from  insanity 
in  its  shorter  duration,  the  absence  of  premonitory  symptoms,  and  its 
sudden  outbreak,  its  symptomatic  character,  the  presence  a  high  degree 
of  fever — although,  in  acute  delirium,  owing  to  its  short  duration,  that 
psychologically  organized  transformation  of  the  personality  observed  in 
so  many  mental  diseases  is  never  present,  still,  both  kinds  of  disorders, 
as  regards  their  nature — nervous  irritation,  hypersemia  or  inflammation  of 
the  brain,  probably_  of  its  surfaces — and  causes — sympathetic  irritation  of 
other  organs,  emotions,  anaemio  states,  abuse  of  alcohol,  etc. — are  identi- 
cal; there  are  manias  which  are  transitory  and  of  short  duration,  there  is 
a  kind  of  insanity  which  is  accompanied  by  fever,  and  not  unfrequently, 
the  cerebral  affection  has,  even  in  mental  disease,  a  symptomatic  signifi- 
cation. So  we  may  correctly  designate  the  psychical  disturbance  in 
insanity  as  a  generally  chronic  delirium,  and  we  have  no  groun^ds  for 
agreeing  with  Georget  and  Burrows  in  their  views  as  to  the  specific 
difference  between  the  delirium  of  fever  and  mental  disease. 

See  Georget,  'Ueber  die  Verriicktheit,'  translated  by  Heinroth,  Leipzig,  1821, 
p.  127  ;  Burrows,  '  Commentai-ies  on  Insanity,'  London,  1828  ;  Jacobi,  '  Beobach- 
tungen  iiber  die  mit  Irresein  verbundenen  Krankheiten  ;'  Elberfeld,  1830 ;  Moreau,. 
'  Annal.  Med.  Psychol.,'  vii.,  1855,  p.  20,  and  Bousquet's  review  of  Moreau's  work, 
ibid.,  p.  448 ;  Fee,  'Bull,  de  I'Acad.  Imp.  de  Med.,'  vol.  xx.,  1855,  p.  1213. 

Sectiq]!^  II. — The  General  Diagnosis  of  Mental  Disease. 

§  69.  The  question  whether  an  individual  be  insane  may  be  put  in 
two  different  senses.  It  may  be  asked  whether  in  him  the  general  men- 
tal disturbance  is  the  result  of  disease  ?  or  it  may  be  demanded — in  evi- 
dently present  and  established  morbid  psychical  disturbance — whether 
this  belongs  to  one  of  those  cerebral  affections  which  are  usually  called 
"mental  diseases,"  or  whether  the  disorder  does  not  perhaps  depend  on 
some  other  disease,  as  meningitis,  typhus,  intoxication,  etc.  ?  The  latter 
question  is  purely  medical,  the  former  is  more  frequently  medico-legal. 

When  the  mental  faculties  in  a  man  are  in  a  state  of  morbid  distur- 
bance, this  may  in  some  cases  be  easily  and  by  any  layman  distinguished; 
in  many  other  cases  the  decision  on  this  point  is  very  difficult,  and 
requires  prolonged  observation  and  intelligent  acquaintance  with  the 
science  of  mental  disease.  I  have  had  submitted  to  me  opinions  of  special 
medical  psychologists,  who,  after  six  months'  observation  of  a  patient  in 
their  asylum,  could  not  come  to  a  decision  whether  they  should  declare 
him  insane  or  not;  and  older  and  recent  cases  have  been  published  (Eeiner 
Stockhausen)  on  which  the  opinions  based  upon  long  observation,  insti- 
tuted adlioc,  of  eminent  psychologists  have  been  quite  contradictory:  the 
reading  of  these  is  very  instructive.  We  see,  likewise,  how  very  inadmis- 
sible, in  many  cases,  is  the  demand  frequently  made  on  the  medical  jurist 
(by  the  jury)  that  he,  after  one  or  two  short  examinations  of  the  prisoner, 
should  give  his  opinion,  when,  sometimes,  the  time  allowed  is  insufficient 
to  enable  him  to  acquire  a  full  knowledge  of  the  subject  of  investigation. 

The  difficulty  of  this  question  depends  on  the  fact  that  perversities 
of  feeling  and  effort,  false  ideas  and  opinions,  and  even  delusions  of  the 
senses — all,  as  we  have  seen,  essential  elements  of  mental  diseases — are 
also  produced  in  other  than  morbid  states,  and  can  exist  together  with 
wholly  undisturbed  mental  health ;  further,  that  when  such  psychical 
anomalies  do  not  at  all  exist,  their  prominent  symptoms  may  be  design- 


ON    INSANITY    IN    GENERAL.  81 

edly  imitated ;  or,  when  they  do  exist,  these  may  be  concealed  ;  finally,  on 
the  fact  that  there  are  many  cases  where  the  disease  is  partially  developed, 
and  with  but  incompletely  marked  signs,  which  constitute  the  chief  cri- 
teria from  which  an  individual  is  to  be  pronounced  insane. 

§  70.  (1)  The  chief  point  is  invariably  this — that,  in  the  great  majority 
of  cases,  there  appears  with  the  mental  disease  a  change  in  the  mental 
disposition  of  the  patient  in  his  sentiments,  desires,  habits,  conduct,  and 
opinions.  He  is  no  more  the  same  ;  his  former  /  becomes  changed,  he 
becomes  estranged  to  himself  (alienated)  (see  §  5).  In  order  to  prove 
that  this  change  has  taken  place  in  the  patient,  it  is  necessary  that  his 
former  habits  and  character  should  be  made  known  to  the  physician, 
even  though  solely  from  the  communication  of  others.  The  contrast  is 
then  often  very  striking — the  temperate  man  gives  himself  to  drunken- 
ness, the  frivolous  pores  over  the  Bible,  the  bashful  becomes  impudent, 
the  moral  obscene,  etc.  This  change  in  the  mode  of  thought,  in  the  affec- 
tions and  actions,  is  more  evident  the  more  rapidly  it  occurs,  and  more 
difficult  to  prove  when  it  comes  on  gradually  in  the  course  of  years. 
Cases  of  the  latter  kind  are,  if  the  insanity  be  limited  to  a  slight  degree, 
often  very  difficult  to  distinguish  from  eccentricity,  immorality,  capri- 
ciousness,  or  false  views  of  life.  In  certain  cases,  which  however  are  not 
common,  no  marked  change  can  be  distinguished,  but  rather  a  stronger 
development  and  increase  of  prominent  peculiarities  of  character ;  and 
when,  in  such  cases,  the  mental  disturbance  comes  on  slowly  and  grad- 
ually, it  is  difficult  satisfactorily  to  prove  insanity  :  this  is  seen  in  many 
cases_  of  gradually  increasing  morbid  desire  for  law-suits,  in  slowly  in- 
creasing sensuality  and  ill-temper.  This  change  is  also  wanting  in  con- 
genital cases,  and  such  as  have  existed  from  early  youth;  also  in  individ- 
uals who  have  been  all  along  eccentric,  peculiar,  or  mentally  weak  ;  and 
in  these  cases,  when  moderate  in  degree,  it  is  often  extremely  difficult  to 
diagnose  the  presence  of  disease  (this  difficulty  is  also  felt  when  called 
on  to  distinguish  between  a  slight  degree  of  mental  weakness  or  dementia 
and  stupidity),  while  peculiarities  acquired,  and  changes  of  the  normal 
individuality  still  going  on,  are  generally  more  easy  to  determine.  From 
all  this  we  learn  that  comparison  with  the  former  ways  of  the  individual 
must  always  be  a  principal  element  in  the  consideration  of  these  ques- 
tions. 

We  must  therefore  make  ourselves  acquainted  with  the  antecedents,  the  his- 
tory, of  the  individual.  Unfortunately,  we  are  not  always  assisted  in  this  by  the 
friends  and  relatives  of  the  patient,  but  frequently  left  ignorant,  through  their 
silence,  of  the  most  essental  circumstances  ;  we  often  learn  more  indirectly. 
Likewise,  in  the  short-lived  transitory  insanity,  as  frequently  presented  in  epilep- 
tics, in  drunkards,  and  sometimes,  without  special  cause,  in  those  predisposed, 
the  total  change  of  the  personality  during  the  attack  is  an  important  point ;  but] 
indeed,  the  life  of  an  individual  may  be  such  externally  that  the  greatest  contrast 
to  his  acts  is  seen  during  the  "attack,"  while  a  knowledge  of  his  inner  life  mio-ht 
show  the  cause  of  the  emotion,  in  the  disposition  naturally  strongest,  though 
perhaps  more  or  less  externally  concealed,  from  which  these  acts  emanated.  We 
must,  therefore,  be  very  cautious  with  regard  to  transitoiy  insanity,  which  is 
quite  familiar  to  many  medical  jurists  (see  Devergie,  '  Oii  finit  la  Raison?  ou  com- 
mence la  Folie?  '  "  Memoires  de  I'Acad.  de  Med.,"  vol.  xxiii.,  1859),  and  generally 
can  be  recognized  even  where  the  attack  presents  a  dreamlike  character,  and 
where,  ordinarily,  the  change  of  the  personality  is  most  complete.  We  should  in 
all  such  cases  note  well  the  presence  or  absence  of  any  premonitory  symptoms  ; 
complete  absence  of  such  is  suspicious. 

§  71.   (2)  Should  the  consequent  change  in  the  habits  of  the  patient 
or  the  suspected  exaggeration  of  certain  nluises  of  his  individuality  have 
6  ^ 


82  ON    INSANITY    IN    GENBRAi. 

occurred  under  circumstances  which,  according  to  experience,  may  be 
viewed  as  causes  of  insanity,  or  if  the  individual  has  been  so  situated  as 
to  be  exposed  to  important  exciting  causes,  we  can,  with  still  greater  con- 
fidence, pronounce  his  state  to  be  one  of  mental  disease.  Hereditary 
predisposition,  nervous  constitution,  injuries  to  the  head,  dissipation, 
hysteria,  epilepsy,  may  be  mentioned  as  examples  of  the  most  important 
predisposing  causes  ;  while  disappointment,  fright,  acute  disease,  the 
puerperal  state,  are  amongst  the  most  frequent  exciting  causes  :  the  causes 
will  be  more  closely  considered  in  the  following  book.  But,  here  also, 
there  is  great  difficulty  in  proving  and  judging  of  the  facts.  The  judg- 
ment is  particularly  difficult  in  those  cases  where  there  are  circumstan- 
ces which  are,  indeed,  important  causes  of  insanity,  which  in  themselves 
might  be  considered  as  symptoms  of  mental  derangement,  but  which  are 
also  very  often  presented  as  appearances  of  immoral  desires,  and  have, 
without  anything  morbid,  a  demoralizing  and  degrading  influence  on 
the  character,  sentiments,  and  intelligence.  Thus,  a  dissolute  life,  and 
particularly  the  abuse  of  alcoholics.  Whether  the  perversity,  the  blunt- 
ing of  the  feelings,  and  the  habitual  ill-humor  of  the  drunkard  in  their 
moderate  degrees  should  be  considered  as  morbid  mental  states,  is  occa- 
sionally a  question  which  can  scarcely  be  satisfactorily  solved.  In  the 
higher  degrees  insanity  may  always  be  admitted.  In  the  same  way, 
judgment  may  occasionally  be  difficult  in  cases  where  very  powerful 
mental  causes,  motives  to  violent  emotions,  have  existed,  and  where 
mental  excitation  or  depression,  with  all  their  consequences,  have  ensued 
as  natural  results  of  that  motive  :  for  example,  very  great  depression 
emotional  after  the  loss  of  a  fortune  or  the  death  of  a  friend,  prolonged 
excitement  after  disease.  The  essential  difference  between  a  melancho- 
lic from  mental  causes  and  a  person  affected  with  sadness  in  a  healthy 
way  by  the  same  cause  is,  that,  in  the  latter  case  reaction  takes  place  on 
removal  of  these  causes  or  on  the  entrance  of  opposite  conditions,  while 
the  melancholic  cannot  rid  himself  of  his  morbid  grief,  and  his  state  con- 
tinues, at  least  for  a  time,  even  after  removal  of  the  external  motive  : 
this  distinction,  however,  can  scarcely  be  employed  as  a  practical  diagnos- 
tic basis.  The  judgment  is,  as  a  rule,  more  easily  arrived  at  when  no 
such  external  occasional  causes  of  the  suspected  state,  of  the  consequent 
change  in  the  habits  of  the  patient,  can  be  discovered — when,  therefore, 
this  change  cannot  be  considered  as  healthy  reaction  from  external  events, 
and  when,  on  the  contrary,  there  exist  prepared  or  predisposing  causes, 
such  as  hereditary  predisposition.  Here  we  discover  one  of  the  most 
essential  elements  of  insanity,  viz.,  abnormal  reaction  from  internal  causes, 
from  an  abnormal  mental  etate.  If  an  individual  has,  on  a  former  occa- 
sion, suffered  from  what  was  unquestionably  an  attack  of  insanity,  this 
is  of  the  greatest  importance,  for  we  know  that  a  disposition  to  subse- 
quent attacks  is  thereby  founded. 

If  it  were  possible,  taking  into  consideration  the  etiological  and  path- 
ogenetic circumstances  spoken  of  in  the  second  book,  to  demonstrate  the 
development  of  mental  disease  purely  objectively,  and  apart  from  will,  a 
very  essential  part  of  the  problem  would  be  solved. 

§  72.  (3)  The  symptoms  of  mental  diseases  consist  only  to  a  small 
extent  of  definite,  isolated,  and  unmistakable  morbid  appearances,  ar.d 
never  in  any  case  of  directly  palpable  and  physical  signs.  They  depend 
essentially  on  the  interpretation  of  the  mental  acts  by  an  observer  ac- 
quainted with  disorders  of  the  mental  functions  and  their  modes  of  expres- 
sion.    Two  individuals  may  say  and  do  the  same  thing;  for  example. 


ON    INSANITY    IN    GENERAL.  83 

they  may  express  their  belief  in  witchcraft,  or  the  fear  of  being  eternally 
lost;  the  intelligent  observer  would  declare  the  one  to  be  healthy  and  the 
other  to  be  insane.  This  judgment  is  come  to  by  a  consideration  of  all 
the  accompanying  circumstances,  and  from  a  knowledge  gained  by  expe- 
rience of  the  various  forms  of  insanity  and  their  accompanying  phenom- 
ena: the  idea  of  being  eternally  lost  is  a  notion  entertained  so  frequently 
by  melancholies,  that  it  must  at  once  awaken  the  suspicion  of  melan- 
cholia, and  we  may  at  once  proceed  to  investigate  whether  the  founda- 
tion of  this  idea  is  really  that  which  is  seen  in  melancholia  and  the  delir- 
ious conceptions  which  accompany  it. 

Should  the  condition  of  the  jjatient  and  the  collective  essential  indi- 
vidual symptoms  correspond  to  the  image  of  one  of  the  principal  forms 
of  insanity  (to  which  all  classifications  must  in  the  end  return  as  they  are 
really  founded  on  nature),  mania,  melancholia,  chronic  mania  or  de- 
mentia, with  the  certain  diagnosis  of  this  form,  of  course  insanity  is 
also  established.  But,  on  the  other  hand,  we  cannot,  as  has  been  already 
seen,  because  the  case  does  not  completely  coincide  with  one  or  other  of 
these  principal  forms,  come  to  the  conclusion  that  no  mental  disorder  is 
present.  These  principal  forms  have  been  established  by  carefully  select- 
ing the  most  characteristic  states  and  connecting  them  into  typical  classes. 
There  are,  however,  many  intermediate  conditions,  mixed  forms,  imper- 
fectly marked  states,  which  do  not  exactly  correspond  to  these  classes. 
Generally  it  is  not  difficult  to  find  out,  at  least,  the  general  character, 
whether  the  state  be  one  of  exaltation,  depression,  or  weakness:  neverthe- 
less, in  certain  cases,  such  as  morbid  dulness  of  sentiment,  mania  for  law- 
suit, etc.,  this  general  character  even  is  not  definitely  marked. 

The  presence  of  a  delusion  is  not  at  all  necessary  to  constitute  an 
individual  insane,  even  in  the  narrowest  sense  of  the  term  (in  contradis- 
tinction to  simple  disturbance  of  the  affective  sentiments).  In  many 
cases  no  special  delusion  is  present,  or,  at  least,  there  is  none  exhibited, 
but  the  sentiments,  dispositions,  and  conduct  are  altered  in  a  morbid 
manner;  and  owing  to  a  morbid  state  of  the  brain,  the  individual  is 
influenced  so  that  the  healthy  faculty  of  judgment  is  obscured,  the  intel- 
ligence formally  involved,  and  the  spirit  held  in  bond.  Such  an  indi- 
vidual can  be  "rational,"  that  is,  can  speak  without  making  great  mis- 
takes on  ordinary  objective  subjects;  he  can  distinguish  right  from  wrong 
— direct  his  actions  with  a  proper  use  of  means,  with  apparent  reflection; 
proves  by  his  conduct  that  he  knows  a  criminal  act,  and  seeks  to  avoid 
the  punishment  thereof,  etc. ;  he  can,  at  least  for  a  time,  so  conduct  him- 
Belf  that  nothing  striking  is  observable,  and  yet  his  disposition  may  be  so 
entirely  altered,  his  whole  affective  sentiments  so  disturbed,  that  an 
essentially  different  relation  of  the  personality  to  himself  (his  former  /) 
and  to  the  world  is  formed,  and  the  irritation  of  sentiment  can,  at  any 
moment,  appear  in  impassioned  perverted  acts  and  desires.  This  is 
particularly  observed  in  the  primary  stages  of  mental  disease,  and  in  many 
moderate  cases  of  melancholia,  in  the  slightest  degrees  of  mania  {folie 
raiso7inante — see  further  on),  and,  very  frequently,  in  the  early  stage  of 
paralytic  dementia. 

In  criminal  cases,  the  act  committed  can  of  itself  often  give  essential 
aid  in  answering  the  question  whether  the  individual  is  mentally  diseased, 
as,  even  in  the  act,  there  often  lies  a  leading  symj^tom  of  the  insanity — 
indeed,  the  only  ground  for  the  assertion  that  insanity  exists.  (I  may 
here  note  the  many  instances  of  murder  of  their  own  children. )  In  the 
great  majority  of  cases,  however,  this  is  inadmissible  and  quite  impossible; 


84  ON    INSANITY    IN    GENERAL. 

we  must  rather,  in  order  to  prove  insanity,  and  that  the  origin  of  the 
deed  proceeded  from  mental  disease,  endeavor  to  establish  before,  exclu- 
sively and  quite  independently  of  the  deed  itself,  the  marks  of  insanity 
according  to  origin,  symptoms,  and  course.  The  opposite  course,  that 
of  making  the  deed  itself  the  distinctive  mark  of  an  abnormal  mental 
state,  has  led  to  the  doctrine  of  instinctive  insanity  (homicidal  mania, 
cleptomania,  etc.),  alike  dangerous  to  science  and  to  practice,  and  has 
only  served  to  bring  the  medical  opinion,  very  properly,  to  bear  upon  the 
judges. 

But,  finally,  are  there  not  cases  in  which,  in  criminal  deeds,  a  mor- 
bid mental  state  exists  and  has  influence,  and  yet  i)resents  no  external 
manifestation?  I  believe  it  possible.  Who  would  dare  to  trust  himself 
to  separate  his  mental  mechanism  as  one  would  lay  open  the  leaves 
of  a  book?  Who  would  dare  to  deny  the  possibility  of  active 
organic  influences  of  a  morbid  nature,  not  externally  noticeable,  when 
disturbed  and  disordered  at  the  moment  of  action,  turning  the  scales 
towards  crime?  In  this  sense  I  was  compelled  to  express  myself  at  the 
bar  in  the  case  of  a  murderer  who  suffered  from  well-constituted  vertigo 
epileptica.  I  was  constrained  to  say  that,  neither  before,  nor  at,  nor 
after  the  deed,  did  we  find  certain  signs  of  mental  disturbance,  yet,  not- 
withstanding, it  was  possible  that  this  disease  allowed  influences  to  act 
on  the  phenomena  of  volition,  which  obscured  reflection  and  weakened 
the  freedom  of  will,  without,  however,  manifesting  themselves  by  any 
external  symptoms. 

§  73.  (4)  Symptoms  of  bodily  disease  ascertained  by  the  6tate  of  the 
pulse,  the  digestion,  the  secretions,  etc.,  cannot  naturally,  in  any  case, 
betaken  as  proofs  of  mental  disease;  the  diagnosis  depends  essentially  and 
exclusively  on  the  mental  symptoms.     Nevertheless  those  symptoms  of 
diseases  in  other  parts  may  be  of  great  value.     From  them  we  are  enabled 
to  answer  the  question,  Is  the  individual  in  a  state  of  general  ill-health? 
If,  from  these  symptoms,  this  can  be  said  with  certainty — if,  on  the  one 
hand,  a  striking  mental  change  is  observed,  or  very  suspicious  behavior, 
and,  on  the  other,  a  general  morbid  state  of  the  organism  be  present — it 
becomes  highly  probable  that  both  series  of  phenomena  are  related  to 
€ach  other,  i.  e.,  that  the  mental  change  is  itself  morbid.     As,  however, 
insanity  depends  essentially  on  an  affection  of  the  brain,  there  are  none 
of  all  the  psychical  symptoms,  not  in  the  narrow  sense,  of  greater  signifi- 
cance than  certain  phenomena  of  disturbed  (irritated,  depressed,  etc.) 
cerebral  function.     Therefore,  anomahes  of  the  central  sensorial  function, 
hallucinations,  etc.,  are  of  such  extraordinary  value,  and  violent  head- 
aches, sleeplessness,  fainting,  anaesthesia,  changes  in  the  pupils,  all  con- 
comitant convulsions  and  paralyses  are  also  of  such  great  importance,  in 
the  diagnosis  of  insanity.     If  these  symptoms  can  be  traced  to  an  affec- 
tion of  the  brain,  and  if  we  can,  by  these,  prove  that  at  all  events  a  cere- 
laral  affection  is  present,  it  is  clear  that  in  few  cases  we  can  doubt  that  the 
suspected  psychical  symptoms  depend  also  upon  the  cerebral  affection;  at 
least  the  opposite  can  seldom  or  never  be  shown.     On  the  other  hand, 
the  non-appearance  of  such  further  symptoms,  and  the  absence  of  all 
physical  disorder  (of  the  pulse,  digestion,  etc.),  can  never  be  takenas 
proof  of  the  absence  of  a  mental  disease  {i.  e.  a  cerebral  affection  of  which 
the  actual  symptoms  are  exclusively  psychical);  we  frequently  meet  with 
cases  of  undoubted  mental  disease,  especially  chronic  cases,  in  which  the 
bodily  functions  remain  unimpaired. 

§  74.  (5)  From  the  physiognomy,  gestures,  words,  and  actions  of  an 


ON    INSANITY    IN    GENERAL.  85 

individual,  we  learn  the  essential  symptoms,  those  of  the  mental  state. 
But  there  are  cases  where  the  external  signs  mislead,  as  tlue  insanity  is 
sometimes  simulated,  or — but  not  so  frequently — feigned.  When  dis- 
simulation is  suspected,  the  following  circumstances  should  esijecially  be 
considered.  The  simulator,  if  he  does  not  possess  special  psychiatrical 
knowledge,  very  seldom  succeeds  in  correctly  feigning  the  symptoms  of 
any  one  form  of  mental  disease.  He  generally  mixes  the  appearances  of 
several  forms  with  each  other,  so  that  an  unnatural  representation  of 
disease  is  offered.  Moreover,  he  usually  overdoes  the  phenomena  of  men- 
tal disturbance.  He  believes  that  all  must  be  reversed;  instead  of  giviug 
expression  to  delirious  conceptions,  he  talks  absurdly,  and  conducts  him- 
self as  if,  in  insanity,  the  greater  part  of  the  intelligence  and  of  the  mem- 
ory must  be  disturbed;  acts  as  if  he  could  no  longer  count,  read,  write, 
or  tell  his  name,  etc.  The  simulator  is  careful,  and  very  often  shows 
great  uncertainty  in  regard  to  how  he  can  best  play  the  fool;  he  exi^resses 
and  withholds  what  would  be  of  advantage  or  disadvantage  to  him.  He 
presents  few  or  no  general  (bodily)  morbid  symptoms;  he  requires  far 
more  rest  and  sleep  than  many  patients,  and  is  incapable  of  continuous 
muscular  exertion  (as  maniacal  excitement  continuing  for  weeks  without 
interruption).  Therefore,  the  quiet  forms  of  insanity  are  more  easily 
simulated  than  the  very  agitated;  the  easiest  mode  of  deception  is  to 
feign  imbecility.  It  may  be  difficult  also  to  give  an  opinion  in  cases 
Avliere  vague  delirium  with  the  character  of  weakness  is  simulated.  Fre- 
({uently,  observation  where  it  is  unremarked  by  the  patient,  and  even  sur- 
prising him  sometimes,  leads  to  our  object;  but  this  we  do  not  require  to 
notice  further.  It  is  not  necessary  in  this  work  that  we  should  enter 
into  the  subject  minutely.  It  is,  however,  important  to  observe  that 
even  the  existence  of  simulation  is  by  no  means  a  certain  evidence  of 
mental  health;  the  insane  themselves  frequently  simulate:  indeed,  there 
is  a  kind  of  morbid  pleasure  connected  with  this  simulating  which  may 
be  compared  to  the  analogous  disposition  noticed  in  hysteria,  but  must 
not  be  identified  with  it.  We  may  also  be  brought  to  the  opinion  that 
the  individual  simulates  morbid  mental  symptoms,  but  that  he  is  neverthe- 
less mentally  deranged,  only  in  a  way  different  from  what  he  simulates:  in 
such  a  case,  naturally,  other  signs  of  insanity  must  be  present. 

Should  we  suspect  that  insanity  which  really  exists  is  feigned  by  the 
patient,  who  is  conscious  of  the  disorder,  which  may  be  affected  particu- 
larly in  the  preliminary  stages,  or  even  occasionally  with  fixed  melancholic 
delirious  conceptions,  when  the  general  disharmony  of  sentiment  has 
again  subsided  (H.  Hoffmann),  a  continuous  careful  observation  of  him 
when  he  thinks  he  is  unnoticed  is  a  most  important  means  of  ascertain- 
ing the  truth:  it  should  be  particularly  observed  how  he  passes  the  night; 
opportunities  should  be  given  him  to  express  himself  upon  various  themes, 
when  he  may  occasionally  betray  himself;  his  writings,  in  which  insanity 
often  appears  more  strikingly  than  in  conversation,  are  specially  to  be 
looked  at. 

That  is  not  dissimultation  when  an  insane  man  denies  that  he  is  ill— energeti- 
cally protests  against  the  suspicion  of  his  being  insane.  A  very  adroit  simulator 
could  also  imitate  this  denial :  ordinarily  this  would  appear  to  him  too  hazardous; 
he  would  show  an  opposite  demeanor,  he  would  readily  declare  liimself  ill,  and 
especially  mentally  ill. 

§  75.  (6)  But,  simulation  excluded,  and  all  that  we  have  hitherto  said 
carefully  considered,  still,  in  many  eases,  the  (juestion  whether  an  indi- 
vidual be  insane  cannot  with  certainty  be  solved.     The  question,  Whether 


86  ON    INSANITY    IN    GENERAL. 

mentally  diseased  or  not?  is  by  no  means  a  correct  one.  There  are  no 
well-marked  boundaries  between  health  and  disease  in  general;  there  is 
in  mental  as  in  other  pathology,  an  intermediate  territory  of  disorder 
which  is  not  yet  fully  developed  disease,  and  where  the  individual  still  ex- 
hibits many  of  the  characteristics  of  health.  Is  not  this  the  case  with  the 
simplest  bodily  troubles?  Where  is  the  exact  point  at  which  we  pronounce 
a  man  blind ?  Only  where  there  is  absolutely  no  appearance  of  light?  Or, 
who  is  dumb?  Who  is  dropsical?  The  individual  who  has  the  slightest 
trace  of  oedema?  If  not,  where  does  the  limit  of  dropsy  commence?  When 
there  are  extremes,  all  are  agreed.  When  the  degrees  are  slight,  we 
may  even  argue  whether  these  signs  may  be  taken  into  consideration  in 
the  case. 

In  mental  medicine,  however,  many  medico-legal  cases  fall  within  this 
category;  for  exam23le,  of  deeds  done  in  passion  by  persons  habitually 
moody,  and  those  of  weak  intellect — of  habitual  moderate  excitement,  or 
of  perverseness  with  temporary  distraction,  of  drunkenness,  hysteria,  etc. ; 
cases  of  which  it  must  ordinarily  be  said  that  the  individuals  are  not  in 
a  healthy  mental  state,  but  the  marks  of  definite  mental  disease  cannot 
be  clearly  discovered;  therefore,  it  is  more  probable  than  certain  that 
their  actions  are  regulated,  or  at  least  greatly  influenced,  by  morbid 
organic  causes.  In  the  mode  in  which  these  actions  are  expressed  there 
is,  indeed,  no  marked  line  of  distinction  between  eccentricity,  passion, 
perversity  of  desire,  dulness  of  sentiment,  and  mental  disease;  there  is  no 
constant  sign  from  which  we  can  tell  Avhether  those  states  result  entirely 
from  organic  disease  (morbid),  or  only  partially  from  such,  or  whether 
they  exist  without  organic  influence,  as  original  traits  of  character,  or  as 
the  hereditary  results  of  the  psychical  individuality.  All  existing  phe- 
noma  of  cerebral  disorder,  hallucinations,  paralysis,  etc.,  and  all  physical 
morbid  appearances,  are  here  of  special  value. 

We  must  bear  in  mind  that  in  very  many  cases  there  are  few  distinct,  clear, 
and  perfectly  demonstrable  signs  of  mental  diseases  or  health — that  the  general 
and  collective  impression  of  tlie  patient  and  his  acts  much  more  determines  the 
opinion.  On  such  a  collective  impression,  however,  only  the  man  who  thoroughly 
understands  the  question,  an  intelligent  physician,  ought  to  proceed.  A  subjec- 
tive view  of  a  case  by  one  man,  who  at  the  moment  cannot  clearly  show  on  what 
individual  grounds  he  forms  his  conclusion,  may  be  highly  valuable — by  another 
man  quite  wortliless.  We  must  not  therefore  believe  that  every  physician  to  an 
asylum  is  capable  of  so  judging. 

§  7G.  It  is  now  evident  that  the  question  whether  an  individual  be 
mentally  diseased  can  only  be  decided  by  a  careful  personal  examination; 
nevertheless,  very  recently,  and  in  some  cases  perhaps  still,  the  physician 
is  expected  to  state  his  opinion  merely  from  a  description  of  the  actions. 
After  becoming  acquainted  with  the  chief  facts  of  the  case,  we  at  once 
proceed  to  a  personal  examination  of  the  patient.  Not  unfref^uent- 
ly,  the  very  state  of  what  immediately  surrounds  him  shows,  to  the 
experienced  eye,  in  the  most  unmistakable  manner  how  matters  stand: 
the  apartment  is  fantasically  decorated,  the  clothing  is  odd,  disorderly, 
torn;  there  are  marks  of  neglect,  of  dirty  habits,  freakislmess,  all  of 
which  were  before  foreign  to  tiie  individual.  In  the  next  place — with- 
out showing  the  patient  that  any  particular  attention  is  directed  to 
him — his  physiognomy,  his  bearing,  his  conduct,  are  to  be  observed,  es- 
pecially in  so  far  as  they  are  expressions  of  certain  dispositions:  the 
countenance  in  the  really  insane  is  frequently  strikingly  altered,  or  irreg- 
ularly distorted,  clearly  expressing  certain  passions  aud  emotions;  the 
voice  may,  ])articularly  in  melancholies,  be  often  takeu  as  a  true  expres- 


ON    INSANITY    IN    GENERAL.  87 

sion  of  the  ruling  disposition.  Conversation  with  the  patient  must,  as 
far  as  possible,  be  carried  naturally  and  calmly;  sympathy  should  be 
shown,  we  shoud  seek  to  rouse  his  attention  and  gain  his  confidence.  In 
general,  it  is  best  to  commence  with  questions  regarding  the  bodily  sensa- 
tion, certain  requirements  or  wishes,  etc. ;  then  to  proceed  to  the  former 
life  of  the  individual,  the  history  of  whicli  we  allow  him  to  relate  in  an 
unconstrained  manner;  hereby  we  seek  to  understand  his  story,  views 
of  life,  interests,  hopes,  and  plans,  in  order  to  receive  from  these,  in 
connection  with  that  communicated  by  others,  a  collective  picture  of 
his  former  individuality.  We  inquire  into  his  present  disposition,  his 
given  intelligence,  his  conduct  (especially  according  to  the  point  of  view 
in  the  preceding  chapter  and  third  book).  In  how  far  these  have  be- 
come altered  in  his  present  state,  what  has  occasioned  these  changes — 
whether  they  are  to  be  considered  as  really  morbid,  whether  any  criminal 
deed  might  result  from  the  morbid  disposition  or  mental  condition — be- 
come now  objects  of  our  judgment;  we  may  conclude  by  a  minute  inves- 
tigation of  the  general  physical  state,  and  an  examination  of  the  several 
organs,  the  lungs,  the  heart,  the  arteries  (so  very  important),  the  organs 
of  digestion,  the  secretions,  etc.  All  signs  of  paralysis,  faltering  in 
speech,  dissimilarity  of  the  pupils,  etc.,  are  particularly  to  be  noted. 
The  primary  stage  of  paralytic  dementia  frequently  appears  in  the  form 
of  folie  raisonnante,  of  perverted  activity  with  relatively  little  disturbance 
of  the  intellectual  faculties,  which  leads  the  patient  to  commit  illegal  acts, 
especially  to  steal.  The  patient  must  continue  under  observation  until  a 
definite  conclusion  can  be  arrived  at,  or  until  it  becomes  evident  to  us 
that  no  decision  can  at  present  be  come  to,  and  that  any  further  exami- 
nation would  elicit  nothing  essentially  new. 

§  77.  The  other  question,  whether  an  individual  whose  psychical 
functions  are  disturbed  suffers  from  a  so-called  mental  disease  in  the  nar- 
row sense  of  the  term  (§  6),  or  from  some  other  cerebral  disturbance  or 
disease,  cannot,  in  many  cases,  be  definitively  solved,  because  various 
kinds  of  cerebral  affections  may  appear  as  mental  diseases  (§  6).  But 
gross  errors  can  and  must  be  avoided;  and  above  all,  we  must  endeavor 
to  establish  a  diagnosis,  in  some  degree  special,  of  the  cerebral  affection. 
The  most  frequent  mistakes  are  made  in  intoxication,  in  typhus  fever, 
and  in  acute  meningitis. 

Intoxication  is  generally  very  easily  distinguished  by  the  smell  of  the 
breath  after  the  abuse  of  alcoholics,  from  the  imperfect  utterance  which 
never  appears  at  the  outset  of  mental  disease,  and  from  the  rapidly  en- 
suing drowsiness  and  desire  to  sleep.  It  has,  however,  been  occasionally 
observed  that  a  fit  of  drunkenness  has  occasioned  the  acute  commencement 
of  insanity  (but  in  every  case  predisposed  from  other  causes),  and, 
further,  that  there  are  certain  specially  predisposed  individuals  who,  even 
after  a  moderate  indulgence  in  the  use  of  spirits,  fall  into  a  state  of  ex- 
citement which  has  more  the  character  of  mania  than  of  drunkenness. 

Typhus  fever,  in  its  first  periods,  occasionally  appears  under  the  form 
of  a  maniacal  attack  with  great  excitement,  attempting  to  get  out  at  the 
window,  etc.,  and  cerebral  congestion,  or  even  under  the  form  of  melan- 
cholia with  stupor;  or  as  a  more  vague  delirium,  in  which  the  patient 
may  walk  about  for  a  certain  time.  In  all  mental  disorders  coming  on 
unexpectedly  in  young  persons,  we  should  keep  in  view  the  probabilty 
of  typhus  fever,  more  especially  when  it  is  epidemic.  First  of  all,  we 
note  the  feverishness  (especially  the  increased  temperature  as  shown  by 
the  thermometer),  the  nightly  exacerbations — the  full,  weak  pulse — the 


88  ON    INSANITY    IN    GENERAL. 

splenic  enlargement,  the  roseola,  the  meteorismus,  the  yellow  flocculent 
stools. 

Not  long  ago,  a  young  man  was  brought  to  me  at  the  hospital  as  mentally  dis- 
eased ;  he  had  for  several  days  shown  symptoms  of  bewilderment,  and  on  the 
previous  night  had  left  his  room  by  the  Avindow  and  proceeded  to  his  office  at  a 
distance.  The  great  uncertainty  of  gait,  complete  incoherence,  hesitation  in 
speech,  marked  inequality  of  the  pupils,  permitted,  in  the  absence  of  other  history, 
the  assumption  of  quickly  developing  mental  disease  with  paralysis  ;  the  hot  dry 
skin,  and  frequent,  full,  compressible  pulse,  awakened  in  me,  at  the  same  time, 
the  suspicion  of  fever.  As  soon  as  the  patient  was  laid  in  bed,  the  diagnosis  could 
with  certainty  be  established  :  the  course  of  the  disease  was  serious,  but  ended 
in  recovery.  It  is  a  well  known  fact  that,  at  one  time,  a  German  psychologist  who 
was  ill  of  typhus  fever  was  sent  to  an  asylum  as  insane  by  one  of  his  colleagues. 

Acute  meningitis  with  strong  inflammation  at  the  convexity  is  mani- 
fested by  violent  headache,  vomiting,  ordinary  delirious  excitement,  con- 
vulsive appearances,  changes  in  the  pu})ils  ;  it  is  always  accompanied 
by  high  fever — the  patient  is  compelled  to  keep  in  bed.  This  disease  is, 
on  the  whole,  rare,  and  its  course  is  rapid;  in  the  majority  of  cases  there 
is  rapid  sinking  of  the  vital  powers;  decreasing  pulse,  coma,  and  destruc- 
tion of  all  the  mental  faculties.  Basilar  meningitis  and  tlie  tubercular 
affections  of  the  membranes  present  essentially  the  same  symptoms,  but 
a  somewhat  more  protracted  and  irregular  course.  As  a  rule,  tuberculosis 
of  the  lungs  may  be  discovered;  where  this  does  not  exist,  the  diagnosis 
from  the  first  form  is,  in  adults,  uncertain.  From  what  has  been  said, 
it  is  certainly  but  seldom  that  these  forms  can  be  confounded  with 
mental  disease  ;  still,  there  are  cases  of  somewhat  protracted  moderate 
tubercular  basilar  meningitis  which  may  again  improve,  and  which  pre- 
sent the  appearances  of  mania  (but  with  convulsion,  contraction  of  the 
cervical  muscles,  etc.),  and  now  and  then,  recent  and  rapidly  fatal  cases 
are  actually  brought  to  asylums  as  cases  of  mania.  From  this  diagnostic 
question,  that  disease  which  according  to  the  older  pathology  was  desig- 
nated meningitis  is  to  be  quite  excluded;  for  the  so-called  chronic  men- 
ingitis there  are  no  completely  satisfactory  diagnostic  signs. 

When,  however,  these  great  mistakes  are  excluded,  when  it  is  clearly 
established  that  the  patient  is  mentally  diseased,  then  commences  a  new 
series  of  diagnostic  questions;  namely,  which  state  of  the  brain  may,  in 
this  concrete  case,  lie  at  the  foundation  of  the  mental  disorder  (§  6). 
In  this,  the  same  fundamental  principles  of  diagnosis  hold  good  as  in  all 
other  affections  of  the  brain.  An  evident  disease  within  the  cranium  is, 
if  any  paralytic  appearances  are  manifested,  probably  unilateral;  states  of 
congestion  are  arrived  at  by  their  well-known  signs  (heat,  redness,  etc.). 
In  the  immense  majority  of  cases  no  definite  anatomical  diagnosis  can 
be  established,  but  the  general  (and  very  important)  symptomatic  phy- 
siological diagnosis,  whether  the  symptoms  represent  more  a  state  of 
active  irritation,  or  of  torpor,  or  of  exhaustion  of  the  cerebral  functions; 
this  is  to  be  determined,  not  by  the  psychical  symptoms  alone,  but  by  all 
the  appearances  collectively.  Now  we  come  to  the  concluding  series  of 
questions — viz.,  whether  the  existing  cerebral  disturbance  is  primary  and 
idiopathic,  or  secondary  and  sympathetic  (from  disease  of  other  organs, 
from  changes  in  the  blood,  etc.);  in  a  word,  the  question  of  pathogenesis, 
the  solution  of  which  is  to  be  sought  from  the  present  symptoms  in  con- 
nection with  the  etiology  and  history  of  origin  of  the  disease  (see  the 
following  book). 


THE   CAUSES    OF    INSANITY.  89 


BOOK  seco:n"d. 

THE  CAUSE  AND  MODE  OF  ORIGIN  OF  MENTAL  DISEASE. 


CHAPTER  I. 
THE  CAUSES  OF  INSANITY. 


§  78.  Under  the  head  of  Causes  in  mental  as  in  general  pathology 
are  nnderstood  all  the  different  classes  of  circumstances  to  which  may 
be  ascribed  an  iniiuence  on  the  development  of  the  disease,  although 
their  mode  of  connection  may  be  variously  exhibited.  The  causes  com- 
prehend, on  the  one  hand,  the  external  circumstances  (nationality, 
climate,  season  of  the  year)  under  the  influence  of  which  insanity  is 
generally,  with  more  or  less  frequency,  observed;  on  the  other  hand,  they 
signify  certain  external  injuries  (sunstroke,  wounds  of  the  head)  of 
Avhich  insanity  is  frequently  a  consequence;  finally,  they  comprehend 
certain  internal  states  dependent  of  the  organism  itself  (hereditary  dis- 
jjosition,  previous  disease,  or  other  general  disturbance  of  the  organic 
mechanism,  such  as  disease  of  the  lungs,  the  genital  organs,  etc. )  which 
we  know  by  experience  have  an  influence  in  the  development  of  insanity. 
In  very  many  of  these  circumstances  the  intimate  connection  between 
them  and  the  influences  ascribed  to  them,  the  mode  in  which  from  them 
the  mental  disease  is  developed,  is  scarcely  ever  or  not  at  all  evident. 
The  conclusion  post  Jioc  ergo  proijter  hoc  dej)ends,  therefore,  only  on  a 
simply  empirical  (statistical)  knowledge  of  the  fact  that  these  particular 
circumstances  (for  example,  hereditary  disposition)  very  frequently  coin- 
cide with,  or  precede,  the  commencement  of  the  insanity.  In  other  of 
these  so-called  causes,  their  mode  of  action,  the  manner  in  which,  in 
consequence  in  them,  the  disease  is  established,  can  be  comprehended. 
But  the  province  of  etiology  in  the  narrow  sense  is  only  to  enumerate 
empirically  the  known  circumstances  of  causation;  it  belongs  to  patho- 
geny to  explain  the  physiological  connection  between  cause  and  effect,  to 
show  the  particular  mechanical  act  by  means  of  which  insanity  is  induced 
through  a  given  circumstance  (for  example,  excessive  depressing  emotion, 
heart-disease,  etc.),  a  task  towards  which  we  have  hitherto  done  little 
more  than  prepare  the  way. 

§  79.  Etiology,  and  especially  pathogeny,  are  of  the  utmost  import- 
ance in  the  j^ractice  of  mental  medicine.  If,  then,  the  old  saying  sublata 
causa  tollitur  effectus  is  no  longer  sanctioned  in  this,  as  in  general'  medi- 
cine, in  fully  developed  and  confirmed  disease,  and  if,  likewise,  the 
removal  of  many  remote  causes  is  beyond  the  power  of  the  physician,. 


90  THE    CAUSES    OF    INSANITY. 

still  we  frequently  see,  especially  in  commencing  insanity,  that  by  removal 
of  certain  of  the  many  ordinary  co-operating  causes,  the  disease  may  be 
successfully  combated,  and  especially  all  the  various  periods  of  transition 
in  the  disease,  all  those  organic  disorders  which  pathogeny  points  out  as 
intermediate  between  the  external  causes  and  the  develojjed  cerebral 
disease  which  is  their  final  result,  present  rich  opportunities  for  medical 
treatment.  Further,  even  the  theory  of  insanity  cannot  be  understood 
without  a  full  knowledge  of  its  causes  and  of  its  mode  of  progress  in  indi- 
vidual cases:  therefore,  the  etiological  questions  are  the  most  important 
iu  tlie  whole  range  of  mental  therapeutics. 

In  concrete  cases,  we  deduce  the  etiological  circumstances  from  the 
history  of  the  case;  and  this  is  always  to  be  collected  with  the  greatest 
care  and  strict  attention  to. the  minute  details.  It  is  here  necessary,  in 
the  first  place,  to  guard  against  the  great  mistakes  of  assuming,  without 
satisfactory  evidence,  the  conjectures  of  those  who  have  hitherto  sur- 
rounded the  patient  regarding  the  origin  of  the  disease,  or,  as  happens 
so  often,  of  considering  as  real  causes  even  decided  symptoms  of  the 
commencing  insanity,  or  only  the  last  accidental  circumstance  which 
caused  its  evident  outbreak.  We  ought  not,  however,  as  a  rule,  to  be 
satisfied  merely  with  the  striking  bodily  or  mental  circumstances  which 
immediately  preceded  insanity,  but  must  assume  a  position  from  which 
the  present  morbid  state  can  appear  as  the  ultimate  result  of  all  the  pre- 
ceding circumstances  of  life.  The  inquiry  into  the  history  of  the  case 
ought  to  embrace  the  whole  of  the  bodily  and  mental  antecedents  of  the 
individual.  It  must  commence  ab  ovo,  indeed  from  former  generations — 
family  predisposition — and  minutely  trace  the  bodily  development,  habit- 
ual state  of  health,  the  nature  of  the  diseases  to  which  the  patient  is 
subject,  and  of  those  which  he  has  already  had.  Likewise,  as  regards 
the  mental  sphere,  we  must  faithfully  and  intelligently  comprehend  the 
relation  of  the  predispositions  and  congenital  peculiarities  of  disposition, 
the  degree  of  education,  and  the  governing  inclinations  of  the  individual 
— his  mode  of  life  and  views  of  the  world,  his  outward  position  and 
the  nature  of  his  thoughts;  thus  endeavoring  to  gain  a  full  picture  of  the 
history  of  the  individuality.  Only  in  this  way  is  an  insight  into  the 
true  history  of  these  diseases  possible;  only  thus  can  we  succeed  in  grasp- 
ing at  their  beginnings  those  fine  threads  which  have  ultimately  en- 
twined themselves  into  delirious  conceptions;  only  thus  can  we,  in  many 
cases  where  insanity  appears  suddenly  and  apparently  without  motive, 
recognize  the  far-back  commencement  of  the  preparation  for  the  disease, 
and  the  almost  mathematical  necessity  of  its  occurrence.  All  this  is  of 
the  highest  importance  in  a  system  of  treatment  which  gathers  from  the 
history  of  the  case  indications,  sometimes  for  the  amelioration  of  invet- 
erate chronic  morbid  processes,  at  others  for  the  removal  of  certain  psy- 
chical causes,  and  which  requires  a  profound  knowledge  of  the  character 
of  the  individual  to  enable  us  to  employ  all  his  inherent  resources  in 
support  of  our  active  treatment. 

The  opinions  of  those  about  the  patient  regarding  the  etiology  of  the  disease 
are  more  frequently  erroneous  than  correct,  and  almost  always  are  at  least  one- 
sided. By  laymen,  and  even  by  physicians,  symptoms  of  commencing  and  occa- 
sionally of  already  confirmed  insanity  are  frequently  regarded  as  causes.  In  the 
commencement  of  the  mental  disease,  a  strong  desire  for  alcoholics,  or  strong 
sexual  irritation  leading  to  excesses  or  to  onanism,  can,  for  example,  appear  as 
sj'mptoms ;  the  already  existing  emotional  excitement  may  occasion  indiscreet 
connections,  rash  speculations,  religious  vexations  and  discussions,  and  the  error 
is  often  committed  of  ascribing  the  disease  to  drunkenness,  unfortunate  love,  an 


THK    CAUSES    OF    INSANITY.  91 

unlucky  venture,  religion,  etc.,  etc.  So,  also,  it  very  often  happens  that  insanity  is 
considered  by  the  friends  of  the  patient  or  by  an  experienced  physician  as  of 
recent  origin,  which,  on  closer  investigation,  shows  itself  to  be  of  many  years' 
standing  and  already  deeply  rooted.  Pinel  himself  relates  the  case  of  a  patient 
who  was  said  to  have  been  nine  months  insane,  while  in  fact  the  disease  had 
existed  for  hfteen  years. 

The  German  psychologists  claim  the  merit  of  having  always  understood  the 
etiology  and  pathogeny  of  insanity  more  thoroughly  and  correctly,  and  of  having 
more  successfully  elaborated  it,  than  the  French  school.  While  the  latter,  partly 
even  in  recent  times  (Moreau  de  Jonnes,  Brierre,  Parchappe),  still  adhere  to 
abstract  tables  of  physical  and  moral  causes,  in  which  drunkenness,  epilepsy, 
ambition,  prostitution,  politics,  loss  of  fortune,  etc.,  are  ranged  as  being  of  equal 
importance,  the  German  psychologists  (Heinroth  and  Ideler  from  the  psychical 
side — Bergmann,  Flemming,  Jacobi,  Jessen,  Nasse,  Zeller,  etc.,  partly  with 
greater  regard  to  bodily  causes)  have  for  long  insisted  on  investigating  the  causes 
in  each  individual  case  ;  and  it  has  been  more  the  plan  with  us  most  carefully  to 
consider  all  the  circumstances,  in  their  various  connections,  which  can  influence 
the  development  of  the  morbid  state. 

§  80.  A  closer  investigation  of  the  etiology  of  insanity  soon  shows 
that,  in  the  great  majority  of  eases,  it  was  not  a  single  specific  cause  under 
the  influence  of  which  the  disease  was  finally  established,  but  a  compli- 
cation of  several,  sometimes  numerous,  causes  both  predisposing  and 
exciting.  Very  often  the  germs  of  the  disease  are  laid  in  those  early 
periods  of  life  from  which  the  commencement  of  the  formation  of  cliarac- 
ter  dates.  It  grows  by  education  and  external  influences,  or  in  spite  of 
these,  and  it  is  but  seldom  that  the  abnormal  psychical  irritability  attains 
either  gradually  or  through  scarcely  noticeable  intermediate  stages  to  an 
evident  disorder  of  mental  function.  More  frequently  there  are  a  gi-eater 
number  of  psychical  impressions  and  bodily  disorders,  by  the  successive 
influences  or  unfavorable  combinations  of  wliich  the  disease  is  developed. 
It  is  then  not  to  be  ascribed  to  any  one  of  these  circumstances,  but  to 
them  as  a  whole.  Thus,  for  example,  we  see  in  the  concrete  cases,  long- 
continued  drunkenness  and  violent  emotion,  hereditary  disposition,  domes- 
tic unquiet,  and  heart  disease — childbirth  and  violent  anger  or  shock — 
disappointed  love  and  commencing  tuberculosis;  in  short,  we  generally 
see  several  injurious  influences  acting  on  the  organism,  or  states  of  disease 
already  present — and  often  more  numerous  and  more  complicated  than 
these  examples — appear  as  causes  of  insanity. 

The  difficulty  lies  in  the  proper  appreciation  of  the  influence  which  each  one 
of  these  circumstances  has  on  the  production  of  the  disease.  We  must  here 
endeavor  by  every  means  to  keep  the  mind  unbiassed  by  this  or  that  theory,  and 
from  one-sided  preference  of  one  or  of  certain  series  of  causes  ;  for  example,  the 
somatic  or  the  mental.  The  judgment  ought  only  to  be  guided  by  a  minute 
investigation  of  the  facts  of  the  case  ;  where  empirical  data  as  to  the  cause  are  in 
any  case  wanting,  they  ought  not  to  be  supplied  by  conjectures,  and  tlie  importance 
of  the  single  circumstances  present  is  to  enable  us  to  conform  to  the  principles  of 
a  rational  pathology. 

An  influence  of  causation  can  naturally  be  attributed  with  most  certainty  to 
those  circumstances  w^hose  mode  of  action  can  be  clearly  traced,  and  whose 
effects  therefore  may  be  considered  as  physiological  necessities ;  or,  where  this 
is  not  the  case,  to  those  whose  influence  is  established  by  reliable  statistics.  A 
slight  gastric  affection,  haemorrhoids,  or  a  transient  cutaneous  eruption,  cannot, 
for  example,  be  considered  as  causes,  because  no  statistics  warrant  the  opinion, 
no  visible  connection  exists  between  these  affections  and  insanity  either  as  to 
their  gravity  or  nature.  On  the  contrary,  disease  of  the  heart  or  of  the  arteries 
are  manifestly  important  etiological  circumstances,  as  they  can  affect  the  circula- 
tion within  the  cranium.  Depressing  emotions  would  appear  to  be  such,  though 
little  is  known  I'egarding  their  mode  of  action,  because  they — as  statistics  incon- 
testably  show — very  frequently  precede  the  coming  on  of  insanity.  The  possi- 
l)ility  of  mental  disease  originating  from  the  irritation  produced  by  intestinal 


92  THE    CAUSES    OF   INSANITY. 

worms  (taenia)  can  scarcely  be  entirely  rejected,  as  we  occasionally  see  other 
serious  cerebral  diseases  (epilepsy)  originate  from  them.  We  should  always  bear 
in  mind  that  anything,  to  be  a  cause,  must  really  precede  the  presumed  effect : 
we  should  not,  for  example,  when  serious  disorder  of  the  digestive  organs  appears 
simultaneously  with  the  commencement  of  insanity,  conclude  that  chronic  disease 
of  the  abdomen  is  the  cause  of  the  insanity.  In  some  cases  all  etiological  data 
utterly  fail,  and  the  insanity  originates  gradually,  like  many  other  chronic  dis- 
eases, from  influences  wholly  unknown.  Nothing  is  more  erroneous  than  here 
to  suppose  an  imaginary  bodily  cause,  and  to  allow  such  a  supposition  to  influence 
our  mode  of  treatment,  as,  even  in  the  present  day,  is  so  often  done,  especially  by 
the  votaries  of  the  so-called  somatic  school. 

§  81.  After  extensive  observation  and  comparison,  we  find  that  the 
etiology  of  insanity  is  in  general  none  other  than  that  of  any  other  cere- 
bral or  nervous  disease.  In  particular,  the  etiology  of  epilepsy  and  of  the 
states  of  chronic  irritation  of  the  spinal  cord  offer  instructive  analogies  as 
Avell  in  regard  to  predisposing  as  to  the  more  immediate  causes.  Ex- 
cluding the  predisposition  circumstances  (period  of  life,  hereditary  pre- 
disposition, certain  errors  in  education),  we  find  that  in  all  these  diseases 
two  distinct  modes  of  origin  may  be  recognized :  in  the  first  place,  an  ori- 
gin (idiopathic)  from  influences  working  directly  on  the  brain — shock, 
injury,  excessive  fatigue  and  exhaustion  of  the  brain  and  entire  nervous 
system,  alcoholics,  narcotics,  excessive  mental  irritation  through  emotion, 
and  the  like;  in  the  second  place,  an  origin  (symptomatic)  resulting  from 
other  further  morbid  changes  in  the  organism  through  which  the  func- 
tion of  the  brain  becomes  affected.  These  different  morbid  states  now 
appear  to  act  upon  the  brain  principally  in  three  different  ways:  in  the 
first  place,  by  generating  or  favoring  anomalies  in  the  circulation  (hyper- 
emia, angemia)  within  the  cranium  (diseases  of  the  heart  and  arteries); 
in  the  second  place,  by  nervous  irritation  of  the  brain,  which  we  can 
scarcely  otherwise  account  for  than  by  communication  and  transmission 
of  peripheral  irritation  of  certain  nerves  to  the  central  organ,  occurring 
to  a  certain  extent  in  a  reflex  manner  (injury  of  a  peripheral  nerve,  influ- 
ence of  the  sexual  organs,  etc. ) ;  in  the  third  place,  by  deficient  nutrition 
and  excitation  of  the  brain  in  consequence  of  dyscrasia  (general  anemia, 
etc.). 

On  this  account,  the  distinction  between  an  idiopathic  and  symptomatic  origin 
of  insanity  cannot  in  the  concrete  cases  be  fully  carried  out.  It  is  here  just  as  in 
epilepsy,  in  which  it  has  been  frequently  attempted.  This  is  explained  by  the 
fact  that,  on  the  one  hand,  in  general  many  injurious  influences  are  at  work 
which  act  in  different  ways  ;  and,  on  the  other  hand,  that  certain  etiological  cir- 
cumstances, especially  the  all-important  pressing  emotions,  not  only  in  different 
cases,  but  also  simultaneously  in  the  same  individual,  may  affect  the  brain  either 
primarily,  or  secondarily  and  indirectly,  in  consequence  of  chronic  affection 
of  other  organs  and  general  destruction  of  the  constitution. 

In  so  far,  however,  as  it  can  be  established  and  proved,  this  distinction  is  very 
valuable.  It  agrees  in  part  with  the  distinction  between  mental  disease  resulting 
from  anatomical  changes  within  the  cranial  cavity,  and  those  existing  without 
any  palpable  disease  of  the  brain  or  its  membranes.  In  the  latter  states  the 
insanity  is  frequently  transient,  dependent  on  morbid  conditions  of  other  organs, 
and  a  purely  functional  disorder  (for  example,  the  hysterical  insanity  from 
anaemia  or  disease  of  the  genital  organs)  :  in  the  first  group,  again,  the  cerebral 
disease  is  more  fixed  and  more  independent ;  for  example,  paralytic  dementia, 
the  chronic  mental  weakness  of  drunkards,  etc. 

In  the  following  remarks  on  the  various  classes  of  etiological  circum- 
stances, their  mode  of  action  will  be  minutely  considered.  In  their 
enumeration  we  shall  adhere  to  the  customary  division  into  predisposing 
circumstances  and  special  causes   (not  altogether  correctly  exciting  or 


THE    CAUSES    OF    INSANITY.  93 

occasional  causes),  which,  notwithstanding  certain  of  the  influences  to  be 
mentioned  (for  example,  disorders  of  menstruation,  psychical  influences), 
can  act  sometimes  as  predisposing,  sometimes  as  exciting  causes.  In  this 
arrangement,  which  at  present  is  the  most  convenient,  any  departure  from 
scientific  exactness  may  be  compensated  for  by  a  careful  analysis  of  indi- 
vidual cases. 


!£  SS- 


94r  THE    CAUSES    OF    INSANITY. 


CHAPTER  II. 
THE   PREDISPOSING    CAUSES    OF   MENTAL   DISEASE. 

§  82.  If  we  consider  the  extreme  frequency  of  all  the  injurious  influ- 
ences which  have  been  enumerated  as  causes  of  mental  disease,  and  the 
comparative  variety  of  their  direct  orgin  from  these  causes,  we  are  of 
necessity  led  to  the  assumption  that  certain  preparatory  circumstances 
are  requisite  in  order  that,  in  individual  cases,  disease  generally,  and  in 
particular  this  disease,  may  arise — that  a  certain  susceptibility  and  pre- 
disposition to  such  diseases  must  advance  to  meet  the  sometimes  slight 
exciting  causes.  Indeed,  in  the  present  state  of  science,  we  are  neces- 
sitated to  admit  this  assumption  in  most  diseases  of  the  nervous  system. 
The  cases  of  injury  are  innumerable,  and  it  is  only  seldom  that  tetanus 
succeeds  them.  Numbers  of  children  suffer  from  worms,  and  few  only 
fall  into  convulsions;  many  individuals  live  under  conditions  Avhich  are 
acknowledged  to  exert  a  powerful  influence  on  the  development  of  men- 
tal diseases,  and  only  a  few  of  them  really  become  insane.  Should  we  at- 
tempt to  explain  these  neuroses,  which  cannot  be  more  definitely  accounted 
for  by  the  assumption  of  a  special  disposition  of  the  nervous  system,  it 
may  appear,  indeed,  that  we  are  but  using  empty  words  concerning  an 
unknown  subject;  but  sometimes  a  more  minute  investigation  permits  u& 
here  to  penetrate  into  the  more  intimate  relations  of  this  disposition. 
We,  know,  for  example,  that  in  warm  countries  tetanus  more  frequently 
suceeds  injury  than  in  our  climate,  that  this  complication  is  favored  by  a 
cold  caught  at  the  time  of  the  accident,  or  by  mental  irritation  and  the 
like.  The  same  may  be  said  of  insanity.  We  know  by  experience  that 
there  are  series  of  circumstances  which  have  a  preparing  and  favoring 
influence  on  its  origin.  The  study  of  the  predisposing  causes  of  mental 
diseases  embraces,  on  the  one  hand,  the  consideration  of  those  more  dis- 
tant relations  which  mjluence  whole  communities,  and  can  only  be  shown 
by  statistics,  their  mode  of  action  on  individuals  being  quite  uninvestig- 
at)le, — viz.,  nationality,  climate,  season  of  the  year,  sex,  age,  difference 
of  social  position,  and  the  estimation  of  their  influence  on  the  origm  of 
these  diseases:  on  the  other  hand,  together  with  these  general  relations, 
we  have  also  to  analyze  the  individual  predisposition  congenital  and 
acquired,  such  as  hereditary  disposition,  education,  constitution,  pecu- 
liarities of  character,  bad  habits,  etc.  Doubtless,  the  predisposing  circum- 
stances are  more  important,  stronger,  and  act  more  frequently  in  the  pro- 
duction of  insanity  than  the  occasional  causes.  He  who  has  a  strong 
individual  predisposition,  especially  if  of  a  certain  definite  kind,  is  endan- 
gered by  the  slightest  occasional  causes;  while  the  man  in  whom  this  is 
entirely  absent  can  be  exposed  to  the  most  serious  conflicts  with  perfect 
safety  to  his  mental  health. 

SECTioisr    I. — General  Predisposing   Causes, 

§  83.  1.  Nationality. — The  idea  of  nationality  includes  a  number  of 
the  most  varied  relations — the  climate,  the  fertility  of  the  soil,  the  prin- 


THE    CAUSES    OF    INSANITY.  95 

cipal  employments  of  the  inhabitants,  the  dominant  religious  creed,  the 
degree  of  civilization,  the  public  morality,  the  previous  lot  of  the  people, 
the  form  of  government,  etc.  These  all  co-operate  to  form  certain 
national  peculiarities  which  are  propagated  as  persistent  types  from  father 
to  son;  but  as  all  these  circumstances  act  only  when  combined  and  asso- 
ciated, it  is  impossible  to  accord  to  each  of  them  individually  its  influence 
on  the  origin  of  insanity — it  is  only  statistically  that  the  reports  concern- 
ing the  frequency  or  rarity  of  insanity  in  the  various  countries  can  be 
compared,  and  even  this  leads  to  little  satisfactory  results.  Of  scarcely 
any  country  in  the  world  do  we  possess  quite  trustworthy  statistics. 
Where  more  exact  reports  are  presented,  they  are  often  rendered  compara- 
tively useless,  owing  to  their  not  being  collected  according  to  the  same 
method,  and  especially — a  great  source  of  diiference  of  numbers — owing 
to  the  mixing  of  two  states  which  ought  naturally  to  be  separated — insan- 
ity proper,  and  idiocy  and  cretinism.  Of  many  districts  our  knowledge 
is  limited  to  an  average  calculation  of  the  number  of  the  insane  in  asy- 
lums, so  various  in  different  countries.  The  unsatisfactoriness  of  this  is 
self-evident.  There  is  still  another  possible  source  of  considerable  mis- 
take which  cannot  be  completely  elucidated,  namely,  the  probably  differ- 
ent duration  of  life  amongst  the  insane  in  different  countries  (where  life 
is  more  prolonged,  the  number  appears  greater).  It  will  be  well,  there- 
fore, to  accept  the  following  statement  with  great  reservation. ' 

§  84.  For  the  countries  of  Germany  there  are  many  statistics  pre- 
pared at  different  times,  and  differing  much  in  value.  We  shall  only 
mention  a  few  of  the  most  interesting. 

In  the  Rhenish  provinces  of  Prussia,  the  number  of  the  insane  in 
relation  to  that  of  the  community  was,  in  the  year  1838,  1  in  1027;  more 
recently  Jacobi  estimated  it  at  1  in  666.  In  Westphalia,  in  1836,  1  in 
1590;  or,  inclusive  of  idiots,  1  in  846.  In  Silesia,  in  1833,  1  in  1160;  in 
1853  there  were  in  this  province  3147  insane,  of  whom  969  were  idiots, 
either  congenital  or  from  early  infancy.  In  the  province  of  Saxony,  in 
1836,  1  in  968.     In  Old  Pomerania,  in  1847,  1  in  931. 

For  Austria  we  have  very  meagre  statistics.  In  1849  there  were,  in 
the  twelve  kingdoms  comprising  the  empire,  with  33,643,000  inhabitants, 
6254  insane  in  asylums  (in  eight  of  these  kingdoms  there  were,  at  that 
time  no  asylums).  In  Moravia  and  Austrian  Silesia  there  were,  in  1857, 
1740  insane,  of  which,  however,  1375  had  congenital  mental  disorders;  so 
that  (excluding  these)  there  were  only  7.8  insane  to  every  10,000  inhab- 
itants. 

More  trustworthy  results  are  afforded  by  the  recent  calculations  made 
in  several  of  the  smaller  German  States.  In  Wiirtemberg,  where  in  1833 
there  was  1  case  of  mental  disease  (exclusive  of  idiots)  to  1500  inhabitants, 
in  1853  there  were  1917  insane  and  3740  congenital  idiots;  of  the  first 
there  was  1  to  943  inhabitants.  In  Hanover  a  calculation  made  in  1836 
gave  as  a  result  3084  insane  (1  to  590  inhabitants).  In  Baden  there 
Avere,  in  1850,  on  the  whole,  about  3000  insane  including  cretins,  or  1  to 
454  inhabitants.  In  the  Palatinate  of  Bavaria  (according  to  Dick),  in 
1856,  there  were  418  insane  (1  in  1374  inhabitants)  and  563  idiots  (1  in 
1030  inhabitants).  In  the  Bavarian  district  of  Upper  Franconia  (accord- 
ing to  Stahl),  there  were,  in  1850-53,  about  450  insane  (1  in  1046  in- 

'  The  following  are  gathered  from  the  best  sources  up  to  1859.  Frequently, 
however,  I  have  been  obliged  to  limit  myself  entirely  to  older  statistics,  owing 
to  the  want  of  reliable  reports  of  more  recent  date.  Quotations  have  only  been, 
made  use  of  in  certain  special  cases. 


96  THE   CAUSES    OF   INSANITY. 

habitants).  In  Oldenburg  there  was,  in  1845,  1  insane  (including  idiots) 
in  636  inhabitants.  In  Brunswick  (including  idiots),  1  in  539  inhabi- 
tants. In  the  Duchies  of  Anhalt,  in  1849,  nearly  1  in  450  inhabitants. 
In  Nassau,  in  1840,  1  in  607— in  1856,  1  in  378  inhabitants.  The  chief 
differences  in  these  figures  do  not  certainly  depend  on  differences  of  the 
actual  number  of  the  insane,  but  rather  on  the  varying  frequency  of 
idiocy  and  cretinism,  and  especially  on  the  fact  that  the  calculations  were 
based  on  different  principles  and  made  in  various  ways.  At  all  events, 
these  recent  calculations  give  the  general  results  that  the  average  num- 
ber formerly  assumed  as  well  for  Germany  as  for  the  other  countries  of 
Central  Europe,  of  about  1  insane  in  1000  inhabitants,  is  much  too  low; 
that  it  should  (including  idiots)  rather  be  taken  at  1  in  500  inhabitants. 
The  lunatic  asylums  of  all  Germany  contained,  in  1852, 11,663  patients 
<Lahr). 

In  France  the  old  statistics  calculate  1  insane  in  1900,  or,  according 
to  the  probably  more  correct  valuation  of  Pierquin  and  Brierre,  1  in  1000: 
a  more  recent  calculation  (1853)  gives  1  in  800  (795  inhabitants).  In  Bel- 
gium the  proportion  stood,  in  1835,  at  1.33  to  1000.  Guislain  considered 
this  number  far  too  small;  but  as  he  repeated  them  in  the  *  Lemons  ora- 
les,'  1853,  it  would  appear  that  up  to  that  date  no  new  calculation  had  been 
made.  Moreover,  the  number  of  the  insane  varies  very  much  in  differ- 
•ent  provinces.  In  Eastern  Flanders  the  proportion  is  1.73;  in  Western 
Flanders,  1.33.  In  Luxembourg,  only  0.51  to  1000  inhabitants.  In 
Ghent  there  is  1  insane  in. 303;  in  the  province,  1  in  1473  inhabitants 
(Guislain,  1853):  in  1853  the  total  number  of  the  insane  amounted  to 
about  5500.  In  Holland  there  were  found,  in  1850,  3056  mentally  diseased 
(1  to  1000  inhabitants).  Schroder  van  der  Kolk  considers  this  estimate 
too  small,  and  that  1  in  800  would  be  more  correct. 

In  England,  Scotland,  and  Ireland,  there  were,  in  1847,  41,810  pa- 
tients in  asylums.  The  proportion  of  the  insane  to  the  population  has 
been  estimated  by  Pierquin  at  1  in  783;  by  Hitch,  for  Wales  alone,  at 
1  in  500;  by  Tuke,  1858,  for  England  and  Wales  (including  idiots), 
1  in  300.  In  Scotland,  in  1855  (including  idiots)  the  proportion  was  1  in 
390.     In  Ireland,  1  in  569. 

For  Denmark  (exclusive  of  the  Duchies  and  the  Colonies)  it  was  calcu- 
lated that  in  1847  there  where  1761  insane,  and  1995  idiots  and  cretins. 
In  the  Faroe  Islands  there  was  1  insane  in  114  inhabitants:  almost  one 
third  of  these,  however,  were  cretins.  In  Norway,  in  1835,  there  was  1 
insane  in  334  inhabitants;  in  1845,  1  in  309 — in  1855,  1  in  239  inhabit- 
ants. Amongst  the  insane,  numbering  6340,  there  were,  however,  4911 
cases  of  mental  weakness,  of  which  almost  two-thirds  were  congenital. 

Kegarding  Italy  and  Spain  no  comprehensive  or  reliable  statistics  are 
known  to  me. 

As  to  the  countries  of  the  East,  no  correct  valuation  can  as  yet  be 
made.  There  are,  however,  a  few  exceptions:  for  example,  Malta,  where 
in  1836  there  was  1  case  in  7-800  inhabitants,  and  the  Greek  population 
of  Smyrna,  where  there  was  1  in  1000  (Horeau).  This  is  not  without 
interest,  as  it  shows  that  in  spite  of  the  great  difference  of  climate,  we 
find  in  these  places,  where  European  civilization  predominates,  the  same 
proportion  of  insane  as  is  found  at  the  same  period  in  European  countries. 
It  is  generally  supposed  that  the  number  of  those  afflicted  with  mental 
disease  is  smaller  in  the  East  than  in  civilized  Europe:  I  will  not  deny 
this,  but  I  have  convinced  myself  than  in  the  towns  a  great  many  insane 
persons  appear  as  beggars,  fanatics,  etc. ;  Cairo  abounds  in  such  semi-  or 


THE    CAUSES    OF    INSANITY.  97 

often  wholly-demented  individuals,  and  he  who  would  form  his  opinion 
from  the  small  number  of  insane  in  the  asylum  at  Boulak,  near  Cairo, 
would  very  much  deceive  himself.  In  general,  the  remarks  of  travellers 
in  half  or  uncivilized  countries  concerning  the  frequency  of  insanity  are 
entirely  worthless. ' 

For  the  United  States  of  America  the  number  of  the  insane  in  the  State 
of  New  York,  in  1825,  amounted  to  1  in  7-800;  in  Massachusetts,  in 
1854  (including  idiots),  to  1  in  302.  In  1849  it  was  calculated  that  in 
the  Union  there  was  1  insane  in  500  inhabitants:  more  recent  reports, 
however,  give  a  much  higher  proportion.  According  to  Brigham,  of 
Boston,  the  proportion  of  the  insane  is  in  North  America  almost  three 
times  as  great  as  in  England — a  consequence  of  the  immense  commercial, 
political,  and  religious  excitement.''  In  the  States  of  La  Plata,  mental 
disease  is  very  frequent  (Saurel).  In  the  East  Indies  it  is  not  rare,  but 
not  so  frequent  as  in  Europe  (Wise,  physician  to  a  lunatic  asylum  in 
Bengal). 

§  85.  From  the  discrepancy  and  insufficiency  of  these  statistics,  it  is 
•evident  that  we  are  deficient  in  the  very  first  elements  necessary  to  the 
solution  of  the  much-discussed  and  ambiguous  question,  whether  the  •pro- 
gress of  civilization  has  increased  the  number  of  these  diseases.  We 
possess  no  trustworthy  statistics  from  uncivilized  countries  to  compare 
with  those  of  civilized,  nor  have  we  from  by-gone  centuries  any  informa- 
tion to  enable  us  to  make  a  comparison  with  present  conditions;  and  even 
if  we  had  such  statistics,  they  would  not  enable  us  to  j^enetrate  entirely 
this  complex  question.  The  question  of  the  influence  of  modern  civiliza- 
tion ought  rather  to  resolve  itself  into  a  series  of  isolated  problems,  such 
as  the  influence  of  the  increasing  growth  of  the  population  in  large  towns, 
the  influence  of  the  manufacturing  industries  peculiar  to  many  country 
places,  the  influence  of  the  diffusion  of  education,  the  press,  etc.  Hither- 
to it  may  be  considered  possible  that  the  constantly  increasing  number 
•of  the  insane  which  is  almost  universally  remarked  is  only  a23parent,  and 
that  it  is  owing  to  the  increase  of  the  population,  the  great  attention  now 
paid  to  mental  diseases,  the  more  exact  methods  employed  to  ascertain 
their  existence,  and  to  the  circumstance  that  all  improvements  in  asylum 
matters  lengthen  the  period  of  life  amongst  the  inmates,  thereby  causing 
the  admissions  greatly  to  exceed  the  number  of  deaths,  and  the  patients 
•consequently  accumulate.  It  is,  I  say,  possible  that  it  may  be  so,  but 
very  improbable;  and  I  would  rather  coincide  with  the  opinion  of  most 
medical  psjxhologists,  that  the  increase  of  insanity  in  recent  times  is  real, 
and  quite  in  accordance  with  the  relations  of  modern  society,  in  wliich 
certain  causes,  according  to  experience,  exerting  a  great  influence,  which 
cannot  however  be  quite  expressed  in  figures,  have  become  stronger  and 
more  extended.  The  progress  of  industry,  art,  and  science  necessitates 
&  general  increase  of  the  cerebral  functions;  the  constantly  increasing  de- 
jjarture  from  simple  modes  of  life,  and  extension  of  the  more  refined 
mental  and  physical  enjoyments,  bring  with  them  desires  and  emotions 
formerly  unknown.  The  general  possession  of  a  liberal  education  awak- 
ens in  the  minds  of  many  a  feeling  of  ambition  which  few  only  can 
gratify,  and  which  brings  to  the  majority  but  bitter  deception.     Indus- 

'  It  may  be  left  to  the  reader  to  judge  of  the  value  of  the  statement  of  Dr. 
Butler,  who  spent  twenty-five  years  among  the  Cherokee  Indians,  that  during 
that  period  he  had  never  seen  a  well-marked  case  of  insanity. — Bucknill  and 
Tuke,  '  Psychological  Medicine,'  London,  1858,  p.  46. 

-  Holland,  '  Chapters  on  Mental  Physiology,'  p.  77. 


98  THE    CAUSES    OF    INSANITY. 

trial,  political,  and  social  agitations  work  destructively  on  individuals,  as 
they  do  on  the  masses;  all  live  faster — a  feverish  pursuit  of  gain  and 
pleasure,  and  great  discussions  upon  political  and  social  questions,  keep 
the  world  in  constant  commotion.  We  may  say,  with  Guislain,  tliat  the 
present  state  of  society  in  Europe  and  America  keeps  up  a  general  half- 
intoxicating  state  of  cerebral  irritation  which  is  far  removed  from  a 
natural  and  healthy  condition,  and  must  predispose  to  mental  disorder: 
thus  many  become  insane.  The  demoralizing  influence  of  large  towns— 
in  Paris  it  is  estimated  that  there  are  63,000  individuals  who  maintain 
themselves  by  dishonest  means  and  at  the  cost  of  society,  in  London  there 
are  thousands  of  children  already  devoted  to  crime  and  prostitution — the 
greater  frequency  of  celibacy,  the  altered  relations  of  religion,  may  be  con- 
sidered as  co-operating  circumstances:  but,  on  the  other  hand,  we  should 
not  forget  tliat  the  greater  diffusion  of  knowledge  and  of  comfort,  and  bet- 
ter hygienic  conditions,  oppose  these  injurious  influences;  that  drunken- 
ness probably  everywhere,  but  certainly  in  those  countries,  such  as  Eng- 
land, where  it  used  to  be  considered  one  of  the  most  powerful  causes,  is 
supposed  to  be  steadily  decreasing;  that  the  community  in  civilized  coun- 
tries has  opened  up  to  it  in  asylums  means  and  ways  of  recovery  which 
were  unknown  to  former  generations  and  to  uncivilized  countries.  These 
circumstances  ought  to  compensate,  at  least  to  a  certain  extent,  for  any 
injurious  influence  of  the  spread  of  civilization. 

It  has  been  said  that  the  numbers  of  the  insane  in  England  have  increased 
ninefold  within  the  last  twenty  years.'  Naturally,  neither  the  population  nor 
the  civilization  has  increased  in  this  proportion.  We  can  speak  of  instances  of 
much  smaller  increase:  for  example,  in  Wiirtemberg,  in  twenty-one  years,  the 
number  of  the  insane  have  increased  from  1  in  1500  to  1  in  943.  It  is,  however, 
in  general,  quite  inadmissible  always  to  at  once  ascribe  that  which  distinguishes 
the  present  generation  from  the  former  to  the  "  progress  of  civilization." 
According  to  this  theory,  one  should  also  attribute  the  increasing  improvements 
in  the  murderous  weapons  used  in  warfare  to  our  higher  state  of  civilization! 
The  above-mentioned  diminution  of  drunkenness  is  a  mark  of  real  civilization 
which  indeed  deserves  the  name:  this  does  not  engender  disease,  but  prolongs 
life,  and  conserves  the  power  and  the  health  of  generations. 

Large  towns  very  evidently  furnish  more  insane  than  country  districts;  but 
whether  manufacturing  or  agricultural  pursuits  have  a  marked  influence  on  the 
frequency  of  insanity — whether  commercial  nations,  as  sijch,  in  this  respect 
acquire  an  unenviable  notoriety— whether  Catholicism  or  Protestantism  favors 
insanity,  and  many  similar  questions,  must  for  the  present  remain  unanswered 
for  want  of  material,  and  owing  to  the  unavoidable  complexity  of  the  influencmg 
circumstances.  It  would  be  useless  to  rush  forward  with  arguments  in  favor  of 
or  against  the  statistics,  and  to  attempt  to  solve  inexplicable  questions. 

It  is  a  remarkable  fact,  that  great  political  agitations  appear  to  have  less  mflu- 
«nce  on  the  frequency  of  mental  diseases  than  might  at  first  be  supposed. 
Esquirol  remarked  this  at  the  time  of  the  first  French  revolution.  Accordmg  to 
many  French  and  German  physicians  (excepting  Brierre),  the  revolutionary  move- 
ment of  1830,  and  especially  of  1848,  gave  rise  to  little  or  no  mcrease  m  the  num- 
ber of  cases  of  insanity.  To  the  laity  the  influence  of  the  revolutions  appeared 
very  considerable,  because  in  these  times  politics  formed  the  subject  of  the 
delirium  in  many  patients:  this,  as  we  have  seen,  is  a  purely  accidental  and 
superficial  relation. 

§  86,  2.  Sex.— The  question  whether  the  one  sex  be  more  disposed 
to  insanity  than  the  other  cannot  be  definitely  answered,  owing  to  the 
want  of  sufficient  statistics.  On  this  subject  there  is  an  abundant  litera- 
ture containing  many  statistics,  but  we  have  no  guarantee  for  their 
correctness;  in  particular,  all  statistics  framed  from  asylum  reports  are 

1  Bucknill  and  Tuke,  '  Psychol.  Med.,'  p.  32. 


THE    CAUSES    OF    INSANITY.  99 

insiiflficient  and  apt  to  mislead.  From  the  very  nature  of  things,  espe- 
cially before  the  recent  improvements  in  asylnm  mutters,  female  patients 
constituted  the  minority  amongst  the  inmates  of  the  asylum;  their  fami- 
lies have  more  hesitation  in  parting  with  them,  and,  besides,  they  are 
more  easily  attended  and  restrained  at  home  than  men:  indeed,  the 
older  statistics  of  Fuchs,'  prejjared  according  to  the  numbers  in  a 
great  many  asylums,  show  a  relation  of  100  men  to  75  women.  France 
and  the  Netherlands  formed,  however,  an  exception;  the  number  of  fe- 
males in  these  countries  being  greater  than  that  of  males.  In  more  recent 
times  the  German  asylums  also  appear  to  contain  considerably  more  males 
than  females:  for  example,  the  asylum  of  Siegburg^  has  in  18  years  re- 
ceived 900  males  and  566  females,  and  that  of  Winnenthal,'  in  10  years, 
396  males  and  251  females;  while  the  French  establishment  St.  Yon 
admitted  in  the  8  years  from  1835  to  1843  exactly  the  same  number  of 
men  as  of  Avomen.  ^ 

From  all  these  statistics,  however,  it  does  not  follow  that  insanity  is 
really  more  frequent  in  the  one  than  in  the  other  sex.  The  statistics  of 
Esquirol,  which  included  70,000  patients  of  all  countries,  but  not  on  that 
account  founded  on  a  more  secure  basis,  showed  a  slight  majority  in  favor 
of  the  female  sex.  For  England,  Norway,  Denmark,  Rusia,  and  North 
America — also  for  the  Prussian  provinces  of  Westphalia  and  Saxony,  and 
for  the  Southern  departments  of  France — the  statistics  have  as  yet  shown 
more  men  than  women;  while,  on  the  other  hand,  in  the  northern  pro- 
vinces of  France,  and  in  the  Netherlands,  the  number  of  females  is  the 
greater.  Likewise  the  older  and  the  new  statistics  (1832  and  1853)  for 
Wiirtemberg,  for  the  Palatinate  of  Bavaria,  and  for  Holland,  show  an 
excess  of  females.  All  these  reports  seem  to  require  confirmation;  they 
do  not  admit  of  a  general  conclusion,  but  show  that  in  different  localities 
different  relations  exist  in  this  respect. 

It  would  be  equally  inadmissible  to  attempt  to  draw  a  priori  conclusions  from 
the  frequency  and  significance  of  several  causes  special  to  the  female  sex.  Tlie 
disorders  of  menstruation,  pregnancy,  childbirth,  are  undoubtedly  circumstances 
which  frequently  become  causes  of  insanity ;  but  there  are  also  in  the  male  sex  a 
series  of  circumstances  special  to  it,  such  as  the  more  frequent  drunkenness, 
mental  exertion,  the  struggle  of  ambition,  the  emotions  and  exhaustions  which 
necessarily  accompany  an  active  life.  The  circumstances  certainly  counter- 
balance the  special  influence  of  the  sexual  process  on  the  origin  of  insanity.  In 
women  we  frequently  find  that  the  more  simple  forms  of  mental  disease  may  be 
more  easily  concealed,  and  admit  of  the  patients  being  kept  at  home;  while  the 
same  forms  coming  on  in  man  render  impossible  the  continuation  of  their  calling 
and  the  maintenance  of  their  social  position. 

As  to  the  influence  of  marriage  or  of  celibacy,  all  accounts  ^  agree  m 
this,  that  insanity  is  more  frequent  amongst  unmarried  men,  and  that 
amongst  women  more  married  persons  become  affected — a  fact  which  can 
only  be  ex})lained  by  the  earlier  marriage  of  the  female  sex.  Of  widowed 
persons  there  are  more  belonging  to  the  female  sex;  this  may  be  owing  to 
their  helpless  and  unprotected  condition  in  such  circumstances.  Certain 
statistics,  as  those  of  Ehenish  Bavaria  for  1856,  show  a  large  proportion 
of  widows.     Zeller,  too,  very  properly  remarks  in  regard  to  the  influence 

'  Prepared  in  the  year  1833;  loc.  cit.,  p.  96. 

"  Jacobi,  '  Die  Hauptformen  der  Seelenstorungen, '  i.,  1844,  p.  573. 
^  Zeller,  '  Report  on  the  Efficacy  of  the  Hospital  for  the  Insane  at  Winnen- 
thal;'  "  Journal  fiir  Psychiatric  von  Damerow  und  Roller,"  1844,  i.,  1,  p.  73. 
"  Parchappe,  '  Annal.  Med.  Psych.,'  1843,  ii.,  p.  867. 
'  Fuchs,  loc.  cit.,  p.  103;  Kostlin,  loc.  cit..  i^  9. 


100  THE    CAUSES    OF    INSANITY. 

of  married  life,  that  if,  indeed,  celibacy  appears  to  present  more  occasion 
to  mental  disorder,  still,  in  not  a  few  cases,  the  marriage  connection  and 
the  misfortunes  resulting  from  it  have  been  the  chief  causes  of  the  dis- 
ease. 

§  87.  3.  Age. — No  period  of  life  assures  absolute  immunity  from 
mental  disease,  but  all  statistics  agree  in  this,  that  ceitaiii  periods 
particularly  and  very  markedly  predispose  to  it. 

During  childhood  (before  puberty)  insanity  is  not  frequent,  but  almost 
all  forms  of  it  occur. 

Those  most  generally  observed  are  the  various  kinds  of  mental  weak- 
ness, from  deficient  mental  development  to  the  most  profound  dementia: 
this  will  be  completely  discussed  in  the  third  book  (Idiocy). 

Next  in  order  of  frequency  come  the  maniacal  conditions  in  their 
various  degrees  and  modes  of  appearance.  Sometimes  they  appear  as 
persistent  or  even  habitual  moderate  irritability  of  character:  the  child  is 
passionately  obstinate,  quarrelsome,  malignant,  and  even  inclined  to 
immorality;  it  is  a  kind  of  moral  insanity,  or  folie  raisonnante,  entirely 
corresponding  to  that  of  adults  (see  further  on),  and  may  very  easily  be 
taken  for  simple  wickedness  of  disposition.  Sometimes  it  is  a  state  also 
persistent,  but  more  intense:  there  is  greater  restlessness,  a  constant  aim- 
less roving,  confusion  of  the  intelligence,  perversion  of  the  emotions,  with 
excitement,  which  (with  the  greater  impairment  of  the  mental  develop- 
ment) sometimes  passes  into  profound  mental  weakness.  It  is  impossible 
definitely  to  distinguish  this  from  the  versatile  form  of  infantile  dementia: 
these  children  cannot  keep  quiet  even  for  a  moment;  tliey  talk  incessantly 
and  incoherently,  pay  no  attention,  canstantly  wander  about,  laugli,  cry, 
etc.;  a  form  in  which,  according  to  Seguin,'  with  suitable  treatment  the 
prognosis  is  not  altogether  unfavorable.  Sometimes  there  are  longer  or 
shorter  attacks  of  really  developed  mania. 

Romberg  ('  Deutsche  Klinik,'  1851.  p.  178)  has  seen  the  case  of  a  child  6  years 
of  age  attacked  by  a  blind  instinct  t(i  destroy,  whereby  it  dashed  everything  to 
pieces,  rushed  along  tlie  street  with  a  knife  in  its  hand,  and  could  scarcely  be  held 
in  restraint  (subsequent  recovery).  Indeed,  we  occasionally  observe  in  still 
younger  children  (of  from  3  to  4  years  of  age)  attacks  of  crying,  of  wild  refracto- 
riness, striking,  biting,  desire  to  destroy,  which  last  only  for  a  time,  and  ought  to 
be  regarded  as  true  mania.  These  sometimes  alternate  with  epileptic  attacks, 
with  chorea,  with  stupor,  with  ecstatic  cataleptic  states  (in  which  the  patients 
remain  for  hours  or  even  for  days  as  if  quite  absorbed,  with  open  eyes,  fixed 
countenance,  and  peculiar  position,  sometimes  suddenly  breaking  out  in  loud 
cries,  etc.),  as  if  there  existed  here  the  most  manifold  intermediate  states  between 
epileptic,  choreic,  somnambulistic,  and  mentally  diseased  states.  In  ordinary 
chorea,  mental  disorders  are  by  no  means  rare;  they  are  sometimes  of  a  slight 
nature,  such  as  weeping  or  laughing  without  motive,  obstinacy,  temper,  forget- 
fulness,  hallucinations:  sometimes,  on  the  contrary,  there  is  an  increasing  state 
of  general  mental  excitation  which  passes  into  maniacal  delirium;  this,  in  the 
height  of  the  excitement,  may  terminate  in  death,  but  it  may  also  end  in  recovery 
or  in  chronic  insanity.  (Marci,  " De  L'etat  mental  dans  la  Choree;"  'Mem.  de. 
I'Acad.  de  Med.,'  xxiv.,  1,  1860,  p.  1.) 

Tlie  melancholic  forms  in  all  their  varieties  are  also  observed,  tliougli 
much  less  freciuently,  in  the  years  of  childhood.  If  carefully  looked  for, 
hypochondria  will  often  be  found  in  children,  especially  where  the 
parents  manifest  excessive  care  of  the  health  of  the  child.  Such  children 
exaggerate  their  slightest  ailments,  attentively  dwell  upon  them,  and 
gradually  lose  all  interest  in  others,  just  as  is  seen  in  the  hypochondriasis 

'  '  Traitement  moral,  Hygiene  et  Education  des  Idiots,'  Paris,  1846,  p.  95. 


THE    CAUSES    OF    INSANITY.  101 

of  adults.  The  children  see  that  because  they  are  unwell,  all  their  whims 
are  gratified,  and  half  designedly  magnify  their  ills.  Simple  melancholic 
states  also  present  themselves,  whose  foundation  is  a  general  feeling  of 
anxiety;  and  the  increase  that  has  been  remarked  in  recent  times  of  cases 
of  suicide  in  the  years  of  childhood  (see  Book  III.,  chapter  iv.)  ought 
also,  to  a  very  great  extent,  to  have  its  source  in  the  existence  of  a  melan- 
cholic disposition.  The  form  of  demonomania  is  also  sometimes  observed. 
Monomania,  on  the  other  hand,  is  uncommonly  rare,  if  it  exists  at  all,  in 
the  years  of  childhood.  No  persistent  ego  is  as  yet  formed  in  which  there 
could  occur  a  lasting  radical  change;  the  mobility  of  this  age  does  not 
allow  single  insane  ideas  to  become  persistent  and  systematized,  as  at  a 
late  period;  but,  on  the  other  hand,  the  various  primary  mental  diseases 
having  the  character  of  irritation,  when  of  a  certain  duration,  lead  almost 
certainly  to  a  state  of  general  confusion  and  dementia:  the  latter  states, 
as  the  intelligence  of  the  child  is  not  yet  confirmed,  rapidly  produce 
arrest  of  development,  when  in  adults  they  would  rather  have  caused 
monomania. 

It  is  a  general  essential  characteristic  of  the  mental  disorders  of  child- 
hood that  they  limit  further  mental  development.  We  are  then,  in  th^e 
concrete  cases,  often  in  doubt  as  to  whether  the  states  of  irritation  pre- 
ceding dementia,  esiJecially  the  exalted  forms,  acted  thus  limitingly,  per- 
haps destructively,  or  whether  they  were  the  expression  of  the  stage  of  a 
cerebral  disease  which  for  a  long  time  had  tended  to  persistent  change  of 
structure  and  degeneration,  and  only  at  the  commencement  gave  for  a 
short  time  symptoms  of  irritation.  Hallucinations  and  fixed  delirious 
ideas  are  much  rarer  in  children  than  in  adults;  the  irritative  forms 
alfect  almost  exclusively  the  sphere  of  the  sentiments  and  instincts. 

As  to  the  more  intimate  foundation  of  mental  diseases  in  childhood, 
they  appear  to  depend  in  part  on  an  original  irritability  of  the  brain 
(often  hereditary),  or  produced  and  maintained  by  injudicious  treatment 
(intimidation,  ill-treatment  of  mind,  intellectual  over-exertion,  dissi})a- 
tion),  partly  on  deeper  organic  disease  originating  spontaneously,  or  after 
injuries  of  the  head  (especially  those  cases  which  lead  rapidly  to  demen- 
tia); they  often  proceed  from  sympathetic  irritation  of  the  brain  trans- 
mitted from  the  genital  organs  (onanism,  approach  and  entrance  of 
puberty).  Again,  chloro-anajmic  states  from  various  causes,  rapid  growth, 
previous  acute  diseases  (typhus,  measles,  etc. )  are  often  circumstances  of 
causation.  Also  after  recovery  such  patients  are  much  disposed  to 
relapse;  their  mental  health  continues  in  danger  during  the  whole  of 
their  lives,  or  they  occasionally  become,  without  being  actually  insane, 
owing  to  an  unfavorable  change  in  their  whole  character,  useless  for  the 
world. 

Thumam  enumerates,  from  statistics  of  21,333  cases  of  insanity,  8  cases  of  chil- 
dren under  10  years  of  age.  Haslam,  Perfect,  Esquirol,  Spurzheim,  Guislain, 
Zeller,  and  myself  have  observed  children  who  suffered  under  well-marked  mania, 
at  the  ages  of  6,  7,  9,  10,  12,  13  years.  Foville  (art.  "  Alienation,"  '  Diet.  d.  Med..' 
i.,  p.  516)  relates  two  cases  of  this  kind.  Jordens  communicates  (' Huf eland's 
Journal,'  vol.  iv.,  p.  224)  the  remarkable  case  of  a  boy  who,  in  consequence  of  an 
accident  in  wliich  some  small  pieces  of  glass  penetrated  into  the  soles  of  his  feet, 
became  maniacal,  and  continued  so  till  their  removal.  Pignoceo  ('  Osserv.  suUe 
Alien,  ment.,'  Palermo,  1841,  p.  34)  mentions  a  case  of  mania  observed  by  him  in 
a  boy  8  years  of  age.  Morel  ('Traite  des  Maladies  mentales,'  Paris,  1860,  p.  101) 
mentions  the  case  of  a  girl,  11  years  of  age,  who  had  attacks  of  fury,  and  at- 
tempted to  murder  her  mother  and  sister.  Stf)ltz  ('Med.  Ja>kfTiT7re"f?'Oesterr. 
Staats,'  Marz,  1844,  p.  257)  narrates  a  very  interesting  case^if  inaiiia  in  a  child  7 
years  of  age  (with  loss  of  speech  and  serious  degeneration  /t  the  anterior  cer.ebrax 


102  THE    CAUSES    OF    INSANITY. 

lobes).  In  the  several  institutions  recently  erected  for  the  reception  of  children 
of  weak  intellect,  there  are  generally  found  also  more  or  less  special  cases  of 
mental  disease.  In  the  institution  at  Mariaberg,  in  Wurtemberg,  I  have  found 
especially  the  slighter  states  of  mania  (versatile  form  of  mental  weakness)  repre- 
sented :  we  shall  enter  more  ininutely  into  this  subject  in  the  chapter  on  Idiocy. 
I  have  recently  seen  a  case  of  mania  connected  with  epilepsy  in  a  child  of  5  years: 
a,  case  of  morbid  anxietv  and  hallucinations,  following  epilepsy,  in  a  very  small 
girl  14  years  old;  and  a  case  of  mental  disorder  after  typhus  fever  in  a  boy  10 

years  old.  »    ,  ., ,  j.        ■■ 

Further  contributions  to  the  study  of  the  mental  diseases  of  chddren  are  found 
in  West,  '  Journal  der  Kinderkrankheiten,'  1854,  xii.,  7,  8,  p.  1;  Rosch, '  Beob.  iiber 
den  Cretinismus,'  ii.,  1851,  p.  81;  Delasiauve,  'Ann.  Med.  Psych.,'  vu.,  1855,  p. 
527;  Paulmier,  '  Sur  les  Aif.  mentales  des  Enfants,'  These,  Pans;  Brierre,  'Acad, 
d.  Sciences,'  7  Juin,  1858. 

§  88.  Mental  diseases  are  more  frequent  between  the  ages  of  16  and 
25  than  in  tlie  years  of  childhood;  the  great  majority,  however,  of  all 
cases  occur  during  the  period  of  highest  maturity— in  the  time  of  the 
corporeal  reproduction  and  mental  activity,  of  marriage  and  of  business, 
between  the  ages  of  25  and  50.     But  here  even  the  reports  before  us  are 
not  sufficiently  satisfactorily  to  enable  us  definitely  to  determine  this 
question,  inasmuch  as  the  greater  number  of  the  calculations '  are  based 
upon  the  ages  of  the  patients  when  admitted  into  the  asylum,  with  which 
naturally  the  age  of  the  actual  commencement  of  the  disease  does  not 
necessarily  correspond,  or  inasmuch  as  only  the  number  of  insane  gener- 
ally of  a  certain  age  at  present  in  a  country  is  mentioned,  without  at  the 
same  time  giving  the  total  number  of  individuals  of  that  age  in  the 
country.'     Were  we  allowed  to  take  as  a  standard  very  carefully  prepared 
statistics  of  a  proportionately  small  number  of  patients,'  it  would  be  seen 
that  the  most  frequent  age  of  the  commencement  of  insanity  is  between 
20  and  30  years,  the  next  between  30  and  40,  and  that  already  between 
40  and  50  the  proportion  is  remarkably  diminished.     For  the  male  sex, 
Zeller  *  gives  the  period  of  from  20  to  30,  and  for  the  female  of  from  30  to 
40,  as  that  at  which  insanity  most  frequently  commences,  and  explains  the 
difference  by  the  fact  that  in  the  latter  period  the  bloom  of  youth  begins 
to  fade,  and  with  this  the  hopes  of  a  fortunate  life  begin  to  disappear: 
this,  he  thinks,  accounts  for  the  greater  number  of  the  attacks.     The 
great  number  of  attacks  Avhich,  according  to  observation  and  also  to 
Parchappe's  calculations,  occur  in  women  of  from  40  to  50  years  of  age, 
may  be  connected  with  the  phenomena  of  involution.     Above  50  years 
of  ao-e,  insanity  is  still  more  frequent  in  the  female  sex.     In  general,  from 
this^age  onwards  the  predisposition  begins  to  decline;  but,  nevertheless, 
there  continues  even  to  the  last  limits  of  human  life  a  certain  inclination 
to  mental  disease,  and  this  at  middle  life  is  not  greatly  diminished: 
indeed,  more  exact  statistics  might  show  that   senile  dementia  exists 
to  such  an  extent  as  to  show  a  large  proportion  for  the  last  years  of  life. 

Moreover,  senile  dementia  is  by  no  means  the  sole  form  of  insanity  occurring 
in  these  years.  Esquirol  saw  two  women,  the  one  eighty,  the  other  eighty-four 
years  old,  recover  from  mania.  Burrows  mentions  a  case  of  melancholia  and 
suicide  in  a  person  aged  eighty-four.     I  myself  have  treated  a  recent  case  of 

'  See  Fuchs,  loc.  cit.,  p.  97;  Quetelet,  p.  443. 

2  For  example,  Kostlin,  loc.  cit.,  p.  8;  Ruer,  p.  9;  and  many  other  statistics. 

3  Zeller,  "Second  Report  on  the  Efficacy  of  the  Hospital  for  the  Insane  at 
Winnenthal,"  '  Medic.  Correspondenzblatt,'  1840,  p.  143, 

■*  'Journal  fiir  Psychiatric,'  i  ,  1,  p.  18.  In  the  Vienna  Asylum,  on  the  con- 
trary, the  maximum  period  seems  to  be  in  men  between  30  and  40,  and  m  women 
between  20  and  30  ('  Report.'  Vienna,  1858). 


THE    CAUSES    OF    INSANITY.  103 

melancholia  in  a  person  eighty  years  of  age,  and  could  narrate  many  other  cases 
of  the  same  kind. 

§  89.  4.  The  question  whether  .social  position  exerts  an  essential 
influence  on  the  origin  of  mental  disease  cannot,  as  Fuchs  very  properly 
observes,  be  determined  by  calculations  based  on  the  number  of  admis- 
sions into  public  asylums,  as,  naturally,  far  more  patients  from  the 
lower  classes  enter  these  institutions.  The  only  authority  on  this  subject 
which  we  can  quote,  and  which  is  known  to  us,  is  Junius,''  who  states 
that  in  England  and  Wales  there  are  8500  poor,  and  only  from  1300  to 
1300  wealthy  persons  in  public  and  private  asylums.  If  we  consider  that 
there  are  far  more  poor  than  rich,  we  can  easily  conclude  that  the  two 
classes  are  about  equally  subject  to  insanity;  nevertheless,  it  is  ordinarily 
assumed  tbat  in  the  better  classes  of  society,  or  rather  in  the  wealthy, 
mental  diseases  are  not  so  frequent  as  in  the  poor.  It  even  appears  that 
the  circumstances  which  act  on  the  one  side  through  greater  direct  exci- 
tation of  the  cerebral  functions,  are  on  the  other  compensated  by  hunger, 
poverty,  and  drunkenness;  while  the  powerful  passions,  as  love,  ambition, 
jealousy,  etc.,  are  alike  frequent  and  originally  as  powerful  in  all  cases; 
but  where  there  is  least  intellectual  culture  they  are  most  insupportable 
and  act  most  destructively. 

As  to  a  special  predisposition  which  results  from  certain  trades  and  employ- 
ments, there  is  almost  nothing  to  add  to  the  foregoing  remarks,  viz.,  that  proba- 
bly those  classes  who  lead  a  fatiguing  and  oppressed  life  of  hard  manual  labor 
are  more  frequently  attacked  by  this,  as  indeed  by  every  other  disease,  than  those 
who  are  engaged  in  the  less  exhausting  mental  labor,  or  who  do  no  work  at  all. 
Should,  therefore,  a  marked  preponderance  exist  in  certain  kinds  of  employments 
— for  example,  in  sailors,  day  laborers,  peasants,  etc.,  or  amongst  merchants, 
officials,  officers,  etc. — we  must  first  compare  the  relative  numbers  engaged 
in  such  professions  to  the  general  population;  and  even  then  we  would  not 
be  warranted  in  concluding  that  it  is  the  profession,  as  such,  which  causes  the 
disposition.  Certain  callings  do  not  of  necessity  give  rise  to  certain  classes 
of  injurious  influences,  but  they  may  present  more  opportunities  which  the 
individual  may  voluntarily  resist:  for" example,  butlers  and  sailors  are,  from 
habits  of  drunkenness,  very  frequently  the  subjects  of  delirium  tremens.  The 
assertion  of  Ferrus,  that  those  professions  furnish  the  greatest  number  of  insane 
which  involve  the  least  amount  of  bodily  exertion,  has  not  been  confirmed 
by  any  trustworthy  statistics. 

§  90.  Certain  vocations  appear  to  enjoy  a  remarkable  immunity, 
while  in  others  the  disposition  to  mental  disease  is  considerably  in- 
creased. Professional  beggars,  according  to  Guislain,^  do  not  become 
insane.  He  ascribes  this  to  the  indifference  of  these  jieople.  Female 
prostitutes  in  large  towns  are  often  attacked  by  mental  disease:  misery, 
destitution,  drunkenness,  violent  passions,  syphilitic  contagion,  etc., 
ordinarily  act  together  in  these  cases.  The  number  of  cases  of  insanity 
occurring  amongst  young  female  teachers  and  governesses  is,  at  all  events 
in  England,  very  great:  Bedlam  received  in  10  years  (1846-55)  110  such 
young  Avomen.  Here  adverse  fortune,  want  of  rest,  excessive  mental 
exertion,  and  a  disagreeable  life  may  be  the  chief  causes. 

Imprisonment  brings  into  simultaneous  action  many  influences  which 
are  dangerous  to  mental  health — remorse,  longings,  concentration  on  one 
small  circle  of  ideas;  sometimes  insufficient  nourishment  and  impure  air, 
want  of  exercise,  etc.     Indeed,  in  all  houses  of  correction,  the  number  of 

'  Fuchs,  loc.  cit.,  p.  106. 
-  '  Beitrage  zur  britt.  Irrenheilkunde,'  p.  8. 

3  'Legons  orales,'  ii.,  p.  22.  Joret  ('Mem.  de  I'Acad.  de  Med.,'  xiv.,  p.  34G) 
shows  that,  on  the  other  hand,  female  beggars  very  frequently  become  insane. 


104  THE    CAUSES    OF    INSANITY. 

cases  of  mental  disease  is  relatively  greater  than  in  the  free  population  of 
tlie  same  age;  but  the  majority  of  these  cases  should  certainly  not  be 
entirely  ascribed  to  the  imprisonment — very  commonly  the  individuals  are 
already  very  strongly  predisjiosed,  and  frequently  the  disease  is  even  more 
than  half  developed  before  he  is  put  into  prison,  inasmuch  as  during 
his  previous  life  the  criminal  has  been  exposed  to  the  influence  of  all  the 
causes  of  insanity.  The  question  still  remains  unsolved,  and  probably  in 
the  present  state  of  our  knowledge  it  cannot  be  solved.  What  is  the  influ- 
ence of  the  various  new  systems  of  punishment  on  the  mental  healtli  of 
the  criminal?  It  appears  certain  that  the  strict  solitary  confinement, 
applied  indiscriminately,  augments  the  number  of  mental  affections; 
that  many  individuals  cannot  stand  it,  and  that  especially  irritable  and 
already  half-deranged  individuals  by  it  become  easily  affected  with  hallu- 
cinations, excitement,  and  insanity;  and  then  frequently,  immediately 
on  being  transferred  to  the  common  prison,  they  rapidly  recover.  It 
appears  also  that  women  and  uneducated  persons  do  not  well  bear 
solitary  confinement.  Where,  however,  all  regulations  are  framed  en- 
tirely with  a  view  to  the  bodily  and  mental  health  of  the  criminals — 
where  the  period  of  solitary  confinement  not  being  too  prolonged,  suffi- 
cient open-air  exercise  is  secured,  and  where  the  feelings  and  ideas  of  tlie 
criminals  are  suitably  excited  and  perhaps  elevated — where,  at  the  same 
time,  attention  is  given  to  symptoms  of  moral  perversion  of  the  senti- 
ments; and  the  first  signs  of  commencing  mental  disorder  are  constantly 
and  carefully  watched,  and  the  individuality  of  the  prisoner  as  far  as 
possible  considered,  the  danger  to  the  mental  health  should  not  here  be 
very  considerable. 

Experience  has  shown,  particularly  at  Lausanne  (Verdeil,  1842)  and  in  Tus- 
cany, that  strict  solitary  confinement  is  considerably  more  prejudicial  to  mental 
health  than  general  imprisonment.  On  the  other  hand,  the  excellently  conducted 
system  of  solitary  imprisonment  employed  at  Bnichsal  does  not,  according  to  the 
report  of  Fiisslin,  show  any  injurious  influence  on  the  mental  health  of  the  pris- 
oners. Also,  in  the  model  prison  of  Pentonville  (London),  according  to  Parrish,^ 
only  13  cases  of  insanity  occur  amongst  every  1000  prisoners.  Solitary  confine- 
ment, however,  does  not  extend  there  for  longer  than  eighteen  months.  Solitary 
confinement  particularly  disposes  to  hallucinations  of  hearing;  this  appears 
to  result  from  the  patients  soliloquizing  and  believing  that  they  hear  others 
speaking. 

From  the  very  interesting  communications  of  Delbriick,  it  would  appear  that 
mental  disease  amongst  criminals  is  more  frequent  in  those  who  have  committed 
crimes  from  passionate  motives  than  in  those  who  have  committed  crimes  against 
property.  It  is  most  frequent  after  murder  and  mortal  injury  than  after  rape 
and  arson.  Amongst  criminals,  two  chief  categories  of  delirium  may  be  distin- 
guished:— 1st,  cases  where  a  solitary  great  crime,  such  as  murder,  with  its  conse-, 
quences,  has  subsequently  produced  a  mental  disorder:  2d,  where  habitual  crim- 
inals become  insane,  owing  to  predisposition  and  the  effects  of  time.  In  the  first 
case,  the  single  criminal  act  is  evidently  the  essential  cause  of  the  insanity;  it 
determines  the  form  of  the  disease  and  the  subject  of  the  delirium.  In  the 
second  case,  the  entire  habits  of  life  and  the  customs  of  the  prison  give  a  peculiar 
impi'ess  to  the  disease.  Insanity  is  generally  developed  during  the  first  years 
of  imprisonment  in  solitary  confinement  in  those  already  distinctly  predisposed; 
it  often  shows  itself  even  in  the  first  months.  In  the  delirious  conceptions,  the 
attempt  to  palliate  the  crime  or  entirely  to  deny  it  is  often  seen,  or  to  picture  to 
themselves  a  speedy  deliverance.  Mention  of  the  crime  usually  evokes,  in  those 
of  the  first  category,  passionate  excitement  or  anxiety,  with  increase  of  the 
delirious  expressions.  Refusing  to  work,  excesses,  refractoriness  are  naturally 
of  daily  occurrence  amongst  these  insane  prisoners. 

Ferrus  (1850)  attempted  to  adapt  the  various  systems  of  punishment  to  the 
different  classes  of  criminals.  He  divides  these  into  three  categories: — 1st.  Intel- 
ligent, energetic,  and  totally  corrupt  individuals — unimprovable  scoundrels.    2d. 


THE    CAUSES    OF    INSANITY.  105 

Such  as  possess  a  moderate  degree  of  intelligence,  a  little  developed  sense  of  duty 
— who  are  indifferent  to  good  and  evil,  and  regardless  of  shame  and  disgrace — who 
have  no  opposition  to  bestow  to  their  evil  inclinations.  3d.  Particularly  dull  in- 
dividuals, who  cannot  estimate  tlie  significance  of  their  deeds,  and  often  even  the 
cause  of  their  imprisonment.  Those  of  the  first  category  should ,  throughout,  be 
subjected  to  solitary  confinement;  those  of  the  second  require  rather  "  Auburn's 
System,"  with  quiet  and  solitarj^  confinement  during  the  night;  those  of  the  third 
cannot  at  all  bear  solitary  confinement.  The  application  of  such  a  classification 
must  be  very  difficult  in  practice. 

On  this  subject,  seeWlirth  'Die  neuesten  Fortschritte  des  Gefangnisswesens,' 
Wien,  1844;  Lelut,  'De  I'Emprisonnement  cellulaire,  etc.;'  Moreau,  Christophe, 
'  Annal.  Med.  Psychol.,'  1843,  vol.  ii. ;  Joret,  "De  la  Folie  dans  la  regime  peniten- 
tiaire,"  '  Mem.  de  I'Acad.  de  Med.,'  xiv.,  1849,  p.  319  (contains  many  interesting 
remarks  upon  female  prisoners  and  their  insanity  and  facts  concerning  the  "silent 
system");  FeiTus,  '  Des  Prisonniers,  de FEmprisonnement,  etc.,'  Paris,  1850;  Fiiss- 
lin,  'Die  Einzelhaft,'  etc.,  Heidelberg,  1855;  Delbriick,  'Zeitschr.  f.  Psychiatric,' 
1854,  xi.,  p.  57;  xiv.,  p.  375;  Pietra  Santa,  'Acad,  de  Medecine,'  23  Januar  and 
17  April,  1855;  Scholz,  'Zeitschr.  der  k.  k.  Gesells.  der  Aerzte  zu  Wien,'  1856,  xii., 
p.  635;  the  reports  of  Mittermaier  in  '  Archiv  desCriminalrechts.' 

§  91.  5.  We  now  mention  the  question  so  often  and  so  variously 
discussed,  of  tJie  influence  of  the  seasons  of  the  year  in  originating 
insanity,  merely  to  call  attention  once  more  to  the  fallaciousness  of  many 
statistical  reports.  From  the  circumstance  that,  according  to  Esquirol's 
tables,  most  admissions  into  several  asylums  took  place  during  the 
summer  months  (May  to  July),  fewer  were  admitted  during  spring  and 
autumn,  and  fewest  in  winter,  it  has  been  concluded  that  insanity 
originates  most  frequently  in  summer.  This  is  a  very  erroneous  conclu- 
sion; for  what  asylum  is  so  fortunate  as  to  procure  a  majority  of  its  cases 
within  two  or  even  three  months  from  the  commencement  of  the  disease?' 
There  exists  no  constant  relation  between  the  commencement  of  insanity 
and  the  admission  into  an  asylum,  and  we  are  at  perfect  liberty  to  frame 
conjectures  as  to  when  these  cases  admitted  in  summer  really  had  their 
commencement,  whether  the  greater  difficulty  of  travelling  in  winter  has 
any  effect  on  the  admissions,  etc.  Statisticians  speak  also  of  the  influ- 
ence of  the  seasons  of  the  year  on  the  single  forms  of  insanity.  Esquirol 
has  asserted,  and  Jacobi  has  proved  the  fact  in  181  cases,  that  in  winter 
the  attacks  of  mania  are  most  seldom — that  they  are  more  frequent  in 
summer,  and  especially  in  spring. 

With  regard  to  the  influence  of  the  moon,  if  not  on  the  origin,  at 
least  in  aggravating  and  modifying  insanity  in  its  course.  This  influence 
is  denied  by  the  great  majority  of  medical  psychologists,  and  that  path- 
ology is  derided  which,  for  example,  would  ascribe  the  periodical  return 
of  the  attacks  of  mania  to  the  influence  of  the  stars,  because  they  coincide 
with  certain  regular  changes  in  the  heavens.  Because  of  this  the  influence 
of  the  moon's  light  upon  the  insane  should  not  be  denied,  for  even  in 
healthy  persons  the  light  of  the  moon  can  peculiarly  affect  the  course  of 
the  thoughts,  giving  rise,  for  example,  to  ardent  and  elegiac  ideas  readily 
disposing  to  sentimental  poetry.  In  the  insane,  who  are  more  powerfully 
and  differently  affected  than  the  healthy  by  various  sensible  impressions, 
this  may,  with  the  absence  of  sleep,  the  view  of  the  full  and  brilliant 
moon,  the  uncertain  light,  the  fleeting  shadows  of  the  clouds,  combined 
with  the  stillness  of  the  night,  or  the  confused  murmurs  which  then  float 
through  the  asylum,  indeed,  create  still  greater  impressions,  more  violent 

'  Winnenthal,  an  institution  solely  devoted  to  curable  cases,  received  in  6 
years  133  cases  of  6  months'  standing,  and  150  of  even  longer  durartion.  Zeller 
'Medic.  Correspondenzblatt,'  Juli,  1840,  p.  143. 


106  THE    CAUSES    OF    INSANITY. 

emotions,  yarious  hallucinations,  etc.  Esquirol  prevented  the  agitation 
which  was  regularly  remarked  in  several  patients  at  the  time  of  the  full 
moon  by  hanging  curtains  on  the  windows. ' 

Section  II. — Special  Predisposing  Causes. 

§  92.  1.  Hereditary  Predisposition.  —  Statistical  investigations 
strengthen  very  remarkably  the  opinion  generally  held  by  physicians  and 
the  laity,  that  in  the  greater  number  of  cases  of  insanity  a  hereditary 
predisposition  lies  at  the  bottom  of  the  malady;  and  I  believe  that  we 
might,  without  hesitation,  affirm  that  there  is  really  no  circumstance 
more  powerful  than  this.  Doubts  have  recently  been  raised  as  to  whether 
hereditary  predisposition  plays  a  more  important  part  in  insanity  than  in 
any  other  disease,  or  whether  it  is  merely  most  sought  for  in  that  disease, 
and  therefore  most  frequently  found.  ^  It  is  quite  possible  that  further 
advances  may  show  that  hereditary  predisposition  exercises  quite  as  great 
an  influence  in  many  other  diseases,  especially  when  more  positive  data 
are  once  obtained  concerning  the  transformation  and  transmission  of 
pathological  states.  At  present,  we  can  claim  for  tuberculosis  alone  an 
influence  of  hereditary  circumstances  in  some  degree  equal  to  that  ex- 
hibited by  mental  diseases. 

In  details,  however,  the  reports  differ  very  considerably,  both  accord- 
ing to  the  experiences  of  the  observer,  and  according  to  the  rank  of  the 
individuals  examined  and  the  locality  in  which  the  investigation  took 
place. 

The  enormous  proportion  given  by  Burrows  (hereditary  predisposition 
in  fths  of  the  cases),  or  the  estimate  of  Moreau,  that  in  j\ihs  of  the  cases 
hereditary  influences  have  been  at  work,  are  proved  by  no  reliable  statis- 
tics. In  the  following  paragra])hs,  we  have  united  the  results  of  a  great 
number  of  reports  of  German,  French,  and  English  asylums. 

Jacobi,  in  230  cases  (of  mania)  found  hereditary  predisposition  pres- 
ent in  only  about  |th;  Bergmann  (1838),  whose  investigations  were  limited 
to  the  statistics  of  one  year,  detected  direct  hereditary  predisposition  in 
^th,  direct  and  indirect  together  in  Jd,  of  the  cases.  Hagen,  in  187 
cases,  found  family  disposition  in  -^d,  direct  hereditary  disposition  (father 
and  mother  mentally  diseased)  in  ^th-i-th.  Flemming  found  it,  at 
Sachsenberg,  in  the  proportion  of  over  |th;  Damerow,  at  Halle,  in  773 
admissions,  found  it  in  ^th.  Martini,  in  Leubus,  had  in  twenty-five  years 
amongst  the  higher  ranks  nearly  -^d  (x^o-tlis),  amongst  the  middle  and 
laboring  classes  somewhat  over  ^th,  "officially  constituted  hereditary 
cases."  At  Colditz,  amongst  77  admissions,  fths  of  the  cases  were  proved 
to  be  directly  hereditary.  Hereditary  predisposition  appears,  on  the  con- 
trary, to  exist  to  a  remarkably  small  extent  in  the  lunatic  asylum  of 
Vienna  (1853-5G). 

In  Bicetre  and  the  Salpetriere,  hereditary  predisposition  was,  accord- 
ing to  an  old  compilation  (8272  cases),  present  only  in  tV*!^5  in  the 
Marseilles  asylum,  Lautard  proved  it  in  only  about  yV^^^-  Esquirol  found 
it  in  the  poor  in  more  than  ^th,  in  the  rich  in  about  fths;  Parchappe,  in 
somewhere  over  ^th;  Guislain,  in  over  ith;  Brierre,  in  almost  half;  Da- 
gonet,  in  Stephansfeld  (in  three  statistics  together),  in  about  ^th  of  the 


cases. 


Webster   (1848)   found    at    Bedlam,    in    1798    patients,   hereditary 


'  Loc.  cit  ,  p.  568. 

*  Neumann,  '  Psychiatrie,'  1859,  p.  141. 


THE   CAUSES    OF    INSANITY.  107 

predisposition  in  almost  ^d  oftener  in  females;  Skae,  in  Edinburgh 
(1851-52),  in  248  admissions,  a  little  over  ^d.  In  a  large  number  from 
English  and  Irish  asylums,  collected  by  Jarvis  (1850),  it  was  found,  in 
44,717  men,  only  in  ^V^h;  in  43,091  women,  only  in  ^\d.  At  Blooming- 
dale  Asylum  (New  York),  from  1841-9,  among  1841  patients,there  were  118 
men  whose  fathers  had  been  mentally  diseased,  and  83  who  had  some 
other  relative  insane;  89  women  whose  .fathers  had  been  insane,  and  67 
who  had  other  relatives  insane  (together  ^th). 

Bini,  in  Florence,  found  hereditary  predisposition  present  in  about  ^ 
of  the  cases.  It  will  be  remarked  that  very  large  statistics  (Bicetre, 
Jarvis),  which  probably  could  only  be  made  with  material  less  carefully 
gathered,  give  a  very  small  proportion;  while  those  from  less  extensive  but 
well-investigated  spheres  of  observation  prove  it  to  be  much  more  frequent. 

The  still  considerable  differences  presented  by  these  figures  might  depend  on 
the  predominance  of  certain  circumstances,  which,  being  very  important,  ought 
to  be  more  closely  considered . 

(1)  Congenital  disposition  to  insanity  is  more  frequent  where  marriages  always 
take  place  amongst  a  limited  circle  of  families,  or  even  in  the  same  families.  On 
the  other  hand,  the  transmission  is  diminished  by  constant  crossing  with  strange 
blood.  The  first  circumstance  is  very  evident  amongst  the  aristocracy  of  certain 
countries,  also  in  the  Jewish  population;  and  it  is  especially  striking  among  the 
English  Quakers.  In  the  Asylum  at  York,  which  is  destined  to  this  religious  sect, 
direct  hereditary  predisposition  can  be  traced  in  one-third  of  the  patients,  indirect 
(mental  disease  in  other  relatives)  in  another  sixth;  therefore,  both  together,  in 
one-half  of  the  cases.  >  Progressive  uninterrupted  transmission  leads  finally  to  the 
special  degenerative  forms  (Morel)— to  imbecility  and  idiocy,  and  with  the  dimin- 
ished capability  of  propagation  of  individuals  of  the  latter  kind,  the  race  gradu- 
ally becomes  extinct.'^ 

(2)  There  exist  further  considerable  differences  in  the  statistics,  inasmuch  as 
sometimes  only  the  cases  where  the  parents  or  grandparents  have  been  insane  are 
included,  while  at  others  the  assumption  of  family  predisposition  is  made  wher- 
ever insanity  is  present  in  any  near  relative  (uncles— blood  relatives— cousins). 
The  latter  appears  to  be  the  more  correct  view,  when  we  consider  that  almost 
always,  besides  hereditary  disposition,  still  further  causes  are  required  for  the 
outbreak  of  insanity;  that,  therefore,  the  present  disposition  may  remain  dormant 
from  want  of  such  further  causes  in  the  nearest  relatives.  That  the  disposition 
exists,  however,  can  be  plainly  proven  by  the  insanity  of  other  relatives. 

(3)  We  do  well  not  to  conceive  of  a  family  predisposition  to  mental  diseases 
as  limited  to  these  alone,  but  rather  to  consider  it  as  a  disposition  to  serious  cere- 
bral and  nervous  diseases  generally.  It  is  not  at  all  rare  to  see  in  a  family  certain 
members  suffering  from  insanity,' others  from  epilepsy,  severe  spinal  irritation, 
hysteria,  neuralgia,  etc.  Rush,-^  for  examples,  relates  the  case  of  a  mechanic 
who  had  two  attacks  of  insanity— the  latter  of  which  ended  his  life.  All  his  six 
children  suffered  from  headache,  but  none  presented  the  least  trace  of  insanity. 
In  this  and  similar  cases,  which  are  by  no  means  rare,  the  disposition  appears  to 
be  able  to  manifest  itself  in  various  forms,  and  occasionally  even  we  see  through 
several  generations  pathological  states  of  the  nervous  system  whicli  at  first  grad- 
ually increase,  and  end  by  passing  into  insanity  proper. 

(4)  An  original  anomalous  disposition  is  also  not  to  be  denied  in  those  cases 
where  one  or  both  parents,  although  not  suffering  under  insanity,  present  a 
striking  eccentricity  or  extravagance  of  character,  and  a  morbid  exaltation  of  the 
passions,  which  strongly  approach  to  insanity;  in  those  cases  also  where  several 
instances  of  suicide  have  occurred  in  near  relatives.  For  suicide,  in  many  cases 
a  symptom  of  developed  serious  mental  disease,  is  in  many  others  at  least  the 
evidence  of  a  weariness  of  life  resulting  from  a  morbid  state  of  the  organism, 
and  which  is  to  be  numbered  amongst  the  primary  foi-ms  of  insanity,  melan- 

'  Julius,  'Beitr.  z.  britt.  Irrenheilkunde.'p.  281. 

^  Morel,  "  Des  Caracteres  de  I'Heredite  dans  les  Maladies  nerveuses,"  '  Archives 
generales  de  Med.,'  1859,  September. 

3  'Med.  Unters.  iiber  d.  Seelenkrankh.,'  translated  by  Konig,  Leipzig,  1835, 
p.  36. 


108  THE    CAUSES    OF    INSANITY. 

cholia;  and  experience  has  frequently  shown  that  the  inclination  to  suicide^ 
which  often  comes  on  in  all  the  members  of  a  family  at  the  same  age,  communi- 
cates itself  by  hereditary  descent.  We  will  also  easily  comprehend  how  that 
weakness  of  character  and  excessive  passionateness  by  which  this  hereditary 
tendency  is  so  frequently  shown,  may,  by  the  co-operation  of  unfavorable  circum- 
stances on  individuals  so  affected,  beget  criminal  actions.  In  like  manner,  we 
occasionally  see  in  certain  families  insanity,  suicide,  crime,  the  result  of  the 
intimate  connection  of  certain  dispositions  of  character  combined  with  each  other, 
alternating  in  a  deeply  deplorable  manner. 

Lautard  (Oppenheim,  'Zeitschrift,'  vol.  xxi.,  p.  16)  relates  the  following 
case:  A  husband  and  his  wife,  the  former  42,  the  latter  36  years  of  age,  became 
insane  and  committed  suicide,  the  one  by  strangulation,  the  other  by  drowning. 
They  left  behind  them  three  children.  The  eldest  daughter  poisoned  herself  at 
the  age  of  24,  after  having  lived  for  a  long  time  in  prostitution.  The  son,  accused 
of  assassination,  strangled  himself  at  the  age  of  21.  The  j^oungest  daughter,  in 
the  sixth  month  of  pregnancy,  threw  herself  from  a  roof.  She  left  behind  her  a 
son,  who,  altliough  very  young,  had  been  several  times  in  prison,  and  at  last  went 
on  an  adventure  to  Egypt. 

Miss  M — ,  of  Ortava,  set.  30,  of  an  old  noble  Spanish  family,  never  contami- 
nated by  any  misalliance,  became  insane.  The  disease  presented  the  form  of 
periodical  changes  of  melancholia  and  mania,  with  a  tendency  to  suicide.  Her 
gi-andfather  committed  suicide  in  his  fiftieth  year.  Of  his  three  sous,  two  spon- 
taneously ended  their  lives  in  the  years  of  their  youth  from  being  crossed  in  love. 
The  third,  the  father  of  Miss  M — ,  showed  such  oddities  and  whims  that  he  was 
considered  almost  insane.  His  son  (the  only  brother  of  the  young  lady),  when  20 
years  of  age,  threw  himself  into  the  sea,  because  he  doubted  the  fidelity  of  his 
lady-love.  His  sister,  although  living  in  the  most  favorable  relations  of  life, 
showed  so  sad  a  disposition  that  her  friends  prophesied  for  her  the  same  fate.' 

But  sometimes  also  we  find  in  those  families  where  individual  members  suffer 
from  insanity,  others  of  remarkably  superior  intelligence  with  or  without  eccen- 
tricities. I  could  name  two  such  examples  from  among  the  great  scientific 
celebrities  of  our  own  time.  It  is  not  improbable  that  great  excitability  of  the 
cerebral  processes,  and  even  those  mental  peculiarities  which  in  certain  individ- 
uals run  into  extravagance  and  eccentricity,  may  in  otliars,  under  favorable 
external  circumstances  and  perfect  physical  health,  appear  in  the  form  of  increased 
activity  and  energy  of  intellect,  and  originality  of  thought.  Moreau  ('  Psycholo- 
gic morbide,'  Paris,  1859)  has  recently  brought  forward  this  question  and  pressed 
it  beyond  its  limits. 

The  entire  assumption  that  hereditary  disposition  generally  plays  an  important 
part  in  the  etiology  of  insanity  has  been  attacked  as  incorrect  by  Schlager 
('Zeitschrift  der  k.  k.  Gesells.  der  Aerzte  zu  Wien,'  1860,  Nos.  34,  35).  He  very 
properly  calls  attention  to  the  inconsiderate  manner  in  which  occasionally  the 
hereditary  predisposition  is  proved  by  physicians.  He  confines  himself  to  the 
most  limited  signification  of  the  word  hereditariness,  and  only  admits  such  cases 
as  hereditary  where  before  or  at  the  time  of  procreation  one  of  tlie  parents  was 
mentally  diseased.  According  to  this  principle,  he  found  hereditary  predisposi- 
tion present  in  only  four  per  cent  of  the  cases.  That  this  critic  overshoots  the 
mark  at  once  becomes  evident,  if  we  substitute  the  question  of  family  disposition 
for  that  of  hereditary  predisposition.  In  page  94  of  the  '  Wiener  Bericht ' 
(Vienna,  1858)  there  are  also  found  sufficient  grounds  for  the  small  number  of 
hereditary  cases  admitted  into  the  asylum  there. 

§  93.  Esquirol  assumed,  and  Baillarger"  has  proved  by  the  statistics 
of  453  cases,  that  insanity  is  more  frequently  transmitted  (indeed,  about 
one-third  oftener)  from  the  mother  than  from  the  father  to  the  children. 
He  found,  at  the  same  time,  that  when  the  mother  Avas  insane  more  of 
the  children  became  so,  and  that  the  transmission  of  insanity  to  sons  is 
as  frequently  from  the  mother  as  from  the  father:  on  the  contrary,  in  the 
case  of  daughters  the  disposition  to  insanity  is  inherited  twice  as  fre- 
quently from  the  mother  as  from  the  father.     It  follows  from  this,  that 

»  '  Anal.  Med.  Psychol.,'  Mai,  1844,  p.  389. 

*  "  Rech.  statist,  sur  I'Heredite  de  la  Fohe,"  '  Annal.  Med.  Psvcn.,'  Mai.  1844, 
p.  330. 


THE    CAUSES    OF    INSANITY.  109 

through  insanity  of  the  mother  the  children  generally  are  more  endan- 
gered than  through  insanity  of  the  father,  and  also  that  it  is  more  espe- 
cially the  children  of  the  female  sex  who  inherit  this  unfavorable  dispo- 
sition. 

Moreover,  experience  shows  that  children  who  are  born  before  the 
period  of  manifestation  of  the  mental  disease  are  less  frequently  attacked 
than  those  born  after  the  parents  have  become  insane.  Occasionally, 
therefore,  cases  also  present  themselves  where  the  children  become 
aifected  before  the  parents,  because  a  number  of  causes  favorable  to  the 
outbreak  have  acted  on  them,  while  the  parents,  more  fortunate,  resist  to 
a  gi'eater  age  these  further  influences. 

Sometimes  hereditary  mental  disorders  present  essentially  the  same 
character  in  parents  and  children,  and  occasionally  also  in  a  whole  line 
of  brothers  and  sisters,  appearing  at  the  same  age  and  terminating  in  the 
same  manner — as  for  example,  by  suicide.  Frequently,  however,  this  is 
not  the  case;  the  psychical  disorder  manifests  itself  in  different  ways, 
partly  dependent  on  external  circumstances.  Morel,  who  has  recently 
investigated  this  subject  in  a  comprehensive  and  judicious  manner,*  men- 
tions the  following  as  the  leading  modes  of  manifestation  of  hereditary 
mental  disorder:  (1)  Such  as  appear  rather  in  the  form  of  extreme  exag- 
geration of  the  nervous  temperament  of  the  parents.  (2)  Those  in  which 
the  disorder  principally  shows  itself  in  evil  desires,  eccentricities,  per- 
verseness  of  every  kind,  the  intelligence  being  well  preserved,  the  disease 
showing  itself  far  more  by  senseless  actions  than  by  insane  thoughts  and 
speech.  (3)  Those  in  which  there  already  exists  an  increasing  limitation 
of  the  intellectual  activity,  mental  dulness  and  weakness:  very  commonly, 
also,  it  is  with  great  difficulty  that  the  individuals  affected  can  direct 
their  energies  to  useful  and  moral  ends.  Frequently  there  is  found  in 
these  cases  all  sorts  of  evil  inclinations,  and  occasionally  even  smallness 
of  the  skull  and  sterility.  (4)  Lastly — Dementia  proper,  from  imbecility 
to  the  highest  degree  of  idiocy  and  cretinism:  these  individuals  have 
often  rudimentary  genital  organs,  are  deaf  and  dumb,  clubfooted,  etc. 
All  these  various  pathological  states  are  (according  to  Morel)  branches  of 
the  same  trunk  in  certain  families.  The  disposition  may  disappear  by 
constantly  renewing  the  blood  by  marriage  with  perfectly  healthy  fami- 
lies; it  is  increased  and  developed  to  the  most  degenerate  forms  by 
further  intermarriages,  by  drunkenness  of  fathers,  etc.  In  this  state- 
ment there  is  a  great  deal  of  truth:  every  physician  who  directs  his  at- 
tention to  this  subject  will  discover  numerous  examples  of  it,  not  only  in 
the  asylums,  but  far  more  frequently  in  ordinary  life,  which  cannot  well 
be  definitely  demonstrated  by  statistics.  The  deterioration  of  a  whole 
race,  as  well  as  the  special  degeneration  of  a  particular  patient,  generally 
occurs  gradually  and  progressively.  For  a  long  time  the  hereditary  in- 
fluence can  be  found  only  in  certain  members  of  a  family;  besides,  others 
often  render  themselves  conspicuous  by  their  uncommon  mental  powers, 
and  the  really  degenerate  character  of  the  disease  may  not  as  yet  mani- 
fest itself  in  those  who  are  attacked.  It  appears,  nevertheless,  that  hered- 
itary influences  may  be  highly  and  quickly  increased  by  drunkenness, 
by  disease,  and,  in  short,  by  various  intercurrent  disorders  of  the  parents 
a,t  the  time  of  procreation;  perhaps  also  by  certain  external  influences. 


'  'Traite  des  Degeuerescences  de  FEspece  humaine,'  Paris,  1853;  'Traite  des 
Maladies  mentales,'  Paris,  1860,  p.  513;  and  the  above-mentioned  work  in  the 
Archives,  1859. 


110  THE    CAUSES    OF    INSANITY. 

especially  of  an  endemic  nature.  Thus  the  severe  forms  may  originate 
at  once,  and  several  or  all  the  children  2:)rocreated  under  such  circum- 
stances may  suffer. 

Of  the  general  diagnostic  characters  of  hereditary  mental  disease  the 
following  may  (according  to  Morel)  be  considered  the  chief: — This  kind 
of  insanity  generally  breaks  out  suddenly  from  insignificant  external 
causes:  it  shows  itself  often  in  marked  emotional  insanity,  the  intelli- 
gence remaining  relatively  intact;  there  are  considerable  remissions  and 
exacerbations.  _  Strong  hallucinations  and  paralytic  dementia  are  some- 
what rare;  while,  on  the  other  hand,  there  exists  a  strong  tendency  to 
delirious_ conceptions.  Although  still  in  a  condition  of  relative  health, 
such  individuals  render  themselves  remarkable  by  their  great  emotional 
excitement,  and,  therefore,  their  greater  dependence  on  the  influence  of 
the  external  world;  frequently,  by  all  kinds  of  originalities  and  eccen- 
tricities; and  occasionally,  along  with  intellectual  and  emotional  perver- 
sions, we  find  them  endowed  with  certain  one-sided  extraordinary  gifts 
or  accomplishments. 

§  94.  2.  Education. — The  direction  which  the  understanding  and 
will  of  an  individual  receives  in  childhood  exercises  a  decided  influence 
on  his  whole  future  life.  The  moral  and  intellectual  influence  of  the 
parents  upon  the  child  is,  therefore,  to  be  mentioned  next  to  liereditary 
influence  as  of  the  utmost  importance.  With  Ideler,  we  are  of  opinion 
that  there  are  cases  of  so-called  hereditary  insanity  which  can  be  traced^ 
not  so  much  to  the  transmission  of  organic  disposition  as  to  a  subsequent 
psychical  continuation  of  peculiarities  of  character,  inasmuch  as  certain 
eccentricities,  odd  and  peculiar  views  and  maxims,  have  been  presented 
to  the  child  for  imitation.  Influences  of  this  nature  are,  from  the  first, 
decidedly  adverse  to  the  development  of  a  healthy  soul-life  in  harmony 
with  the  external  world.  Thus,  in  the  same  manner  as  hysteria  is  trans- 
mitted from  the  mother  to  the  daughter,  so  are  psychical  perversions; 
transmittecl  to  their  children  from  insane  or  silly  parents,  and  passion- 
ateness  and  evil  inclinations  are  impressed  upon  the  youthful  mind.  To 
this  circumstance,  not  unf requently,  also,  may  be  traced  the  fact  that  fam- 
ily life  is  often  disordered,  and  thereby  the  co-operation  of  those  favor- 
able circumstances  so  necessary  to  the  harmonious  development  of  the  in- 
fantile character  is  disturbed. 

Amongst  the  special  errors  of  education  may  be  mentioned,  in  the 
first  instance,  premature  mental  exertion.  This,  with  the  undue  preco- 
city of  the  various  mental  processes  thereby  necessitated,  proportionately 
retards  and  hinders  physical  development;  the  brain  is  overwrought,  and 
the  germs  of  future  weakness  and  disease  are  surely  laid.  Still  more 
serious,  however,  are  perverse  and  unfavorable  influences  on  the  sensa- 
tion and  will  of  the  child.  There  are  cases,  for  example,  where,  by 
undue  severity,  by  the  cold  and  repulsive  demeanor  of  parents  towards 
children — by  protracted  grief,  humiliation,  or  harshness  of  sentiment — 
the  development  of  naturally  benevolent  dispositions  is  hindered,  and  the 
gentler  feelings  stifled.  Thereby  there  is  thus  early  implanted  in  the 
individual  a  painful  opposition  to  the  external  world.  This  is  especially 
apparent  in  certain  strong  benevolent  natures,  whose  warm  and  generous 
inclinations  instinctively  seek  a  return  of  affectionate  sympathy,  by  the 
absence  whereof  they  are  necessitated  to  take  refuge  in  an  imaginary 
world,  and  so  a  pernicious  imaginative  tendency  is  awakened  and  nour- 
ished. Finally,  still  more  destructive  to  the  child  is  that  over-indulgence 
on  the  part  of  parents,  which  curbs  not  the  wayward  development  of 


THE    CAUSES    OF    INSANITY.  Ill 

every  desire  and  inclination,  which  incapacitates  the  child  for  enduring 
suffering  or  pain,  which  renders  him  incapable  of  self-control  or  resigna- 
tion, and  develops,  not  a  strong  and  hardy  nature,  but  a  weak,  soft 
character  which  cannot  stand  the  test;  for  sooner  or  later  the  rude  en- 
counter of  life  must  be  met,  and,  unable  to  support  himself  under  the 
fierce  assault,  he  falls  a  victim  to  all  the  agitating  emotions  and  health- 
disturbing  influences  of  violent  passion. 

See,  in  the  following  book,  the  case  mentioned  by  Pinel  ("  Traite  de  I'Aliena- 
tion  mentale,'"  p.  159). 

§  95.  3.  Mental  and  jjhijsical  constitution. — Our  decision  as  to  the 
physical  constitution  is  generally  founded  on  certain  striking  anatomical 
differences  amongst  individuals," especially  in  relation  to  the  development 
of  the  muscular  system.  We  must  renounce  the  attempt  to  discover  any 
predisposition  to  mental  diseases  in  such  differences;  for  daily  observa- 
tion shows  that  the  weak  and  the  muscular,  and  likewise  dry  and  moist 
constitutions,  are  liable  to  the  attack  of  insanity  in  nearly  equal  propor- 
tions. On  the  other  hand,  there  is  another  constitution,  sometimes  con- 
genital, sometimes  acquired,  which  we  cannot  recognize  anatomically, 
but  which  physiology  permits  us  to  appreciate,  which  materially  predis- 
poses to  mental  disease.  It  is  the  so-called  nervous  constitution— that 
relation  of  the  central  organ  which  we  may  generally  define  as  a  dispro- 
portion between  reaction  and  irritation.  This  state  may  be  confined,  to 
certain  parts  of  the  central  nervous  system;  for  example,  in  the  spinal 
cord  or  in  the  brain.  Very  frequently  it  is  observed  equally  in  all  nerv- 
ous acts.  In  the  sensory  nervous  system,  hypergesthesias  of  various  kinds 
are  observed;  great  sensibility  to  impressions  of  temperature;  spontaneous 
changes  in  the  sensation  of  heat  and  cold:  but  especially  the  presence  of 
numerous  sympathetic  sensations,  and  great  disposition  to  pain.  The 
motory  nervous  acts  are  characterized  by  the  withdrawal  of  all  force,  the 
individual  being  easily  exhausted;  by  a  disposition  to  sudden  extensive, 
but  only  slightly,  energetic  movements;  by  increased  tendency  to  convul- 
sions. In  the  mental  sphere  we  observe,  corresponding  to  the  analogous 
states  of  sensation  and  motion,  great  mental  sensibility— susceptibility  ta 
mental  pain,  and  to  that  condition  in  which  every  thought  becomes  an 
emotion.  Hence  the  rapid  alternations  in  self-consciousness  and  volition, 
leading  on  the  one  side  to  weakness  and  inconsistency  of  will,  and  on  the 
other  want  of  energy,  with  abrupt  and  changeable  jDlans.  _  The  intellect 
at  the  same  time  often  presents  the  same  condition.  This  is  seen  in  those 
who,  even  in  childhood,  are  very  irritable.  The  intellect  is  dispropor- 
tionately developed,  and  constantly  presents  something  unstable.  In  the 
case  of  lively  imaginative  minds  which,  however,  are  deficient  m  depth 
and  endurance,  incapable  of  continuous  exertion,  because  they  address 
themselves  seriously  to  no  single  vocation — in  the  case  of  those  imagina- 
tive second-rate  but  quaint  musicians  and  poets,  or  those  misguided  uni- 
versal geniuses,  who,  with  a  certain  vivacity  and  variety  of  thought,  never 
can  find  composure  or  repose  for  any  arduous  work — should  such  indi- 
viduals in  the  long  run  fall  into  insanity,  we  find  in  all  such  cases  a 
confirmation  of  the  doctrine,  that  only  he  who  has  had  a  correct  under- 
standing can  lose  it,  while,  indeed,  a  really  sound  development  and 
cultivation  of  the  intellect  is  in  no  respect  favorable,  but,  on  the  con- 
trary, is  decidedly  unfavorable  to  the  approach  of  insanity. 

In  the  mental  r-phere.  the  more  immediate  consequences,  the  external  modes 
of  appearance,  of  too  great  irritability,  of  the  irritable  weakjiei^s  (see  p.  39),  are 


112  THE    CAUSES    OF    INSANITY. 

very  various.  Many  of  these  appearances,  however,  may  primarily  be  traced  to 
a  great  tendency  to  mental  pain,  "Where  there  exists  a  very  extensive  sphere  of 
agitation,  the  mental  equilibrium  is  more  easily  disturbed,  the  ego  more  easily 
affected;  from  whence  chiefly  results  the  greater  susceptibility  of  those  individu- 
als who  behave  sometimes  impatiently,  are  excited,  intolerant  of  contradiction, 
aggressive — at  other  times,  evading  all  mental  impressions,  they  reservedly  con- 
centrate their  thoughts  upon  themselves.  Such  individuals,  incapable  of  satisfy- 
ing their  emotional  cravings  by  external  actions,  dwell  in  the  realms  of  imagina- 
tion. To  them  the  world  appears  common,  and  they  fancy  themselves  too  good 
and  too  noble  for  its  pursuits.  Thus  are  produced  various  modes  of  manifesta- 
tion of  the  same  fundamental  state,  which  nevertheless  agree  generally  in  this — 
that  the  disproportion  which  exists  between  the  reaction  and  the  impression 
appears  in  the  higher  degrees  as  extravagance  and  excess.  The  result  is,  that  the 
individual,  with  his  whims  and  unusual  modes  of  reaction,  steps  out  of  the  ordi- 
nary beaten  path  of  humanity,  and  passes  in  the  world  as  an  original,  singular 
man.  Such  individuals  sometimes  exhibit  a  painful  degree  of  scrupulousness 
and  trifling  pedantry  (frequently  this  is  associated  with  mechanical  talent).  At 
other  times  they  are  remarkable  for  frivolity,  irregularity,  uncertainty  of  thought 
and  action — sometimes  for  their  coolness  and  apathy,  or  even  for  their  eccentric 
ardor,  irresolution,  or  audacity.  They  exhibit  striking  peculiarities — at  one  time 
lowness  of  spirits,  at  another  time  enthusiam;  but  they  are  always  changeable, 
always  violent.  The  mode  of  reaction  differs  in  such  cases  from  that  of  the  aver- 
age of  mankind,  and  therefore  seems  freakish.  In  those  passionate,  eccentric, 
often  inwardly  discordant  and  disunited  natures,  bodily  disorder  of  every  descrip- 
tion may  become  truly  dangerous.  They  often  bring  to  rapid  development  the 
■existing  latent  germ  of  mental  disease. 

§  96.  These  mental  dispositions  are  undoubtedly  congenital  and 
inherited;  they  are,  so  to  speak,  not  nnfrequently  the  media  of  the  hered- 
itary predisposition  to  insanity,  and  are  early  evinced  in  the  mental  life 
of  the  child  by  peculiar  directions  of  taste,  uncommon  sensibility,  vola- 
tility of  the  inclinations,  and  little  disposition  for  study;  so  that  sncli 
individuals  are  frequently,  from  the  very  first,  objects  of  solicitude  and 
grief  to  their  parents  and  teachers,  while  they  are  occasionally  the  objects 
of  injudicious  wonder.  Many  of  our  observations,  based  on  the  confes- 
sions of  patients  and  convalescents,  coincide  with  the  statements  of 
Foderi,'  that  in  the  subjects  of  such  dispositions  there  is  frequently  a 
premature  development  of  the  sexual  passion,  and  consequent  spontane- 
ously developed  onanism,  together  with  early  haemon-hoidal  disease  (the 
latter  probably  in  consequence  of  the  irritation  of  the  genital  organs). 

Although  it  may  be  doubted  whether  such  circumstances  act  as  causes  of 
those  psychical  peculiarities,  it  is  nevertheles  worthy  of  careful  consideration  that 
even  in  cases  where  there  is  no  such  congenital  disposition,  we  very  f  requentlj- 
find  the  same  psychical  anomalies  developed  in  later  years  in  consequence  of 
structural  disease  of  the  genital  organs.-  It  need  scarcely  be  stated  here  that 
hysteria,  which  presents  that  condition  of  the  nervous  process  chiefly  in  the 
spinal,  but  frequently  also  in  the  cerebral  system,  often  arises  from  disorder  of 
the  sexual  processes. 

Other  diseases,  especially  all  considerable  losses  of  fluids,  and  the 
states  of  anaemia  and  exhaustion  resulting  therefrom,  are  often  recogniz- 
able as  causes  of  the  acquired  nervous  constitution.  It  appears  at  other 
times  that  local  hypersesthesia,  prolonged  irritation  of  any  particulai' 
nerve,  ^  may  produce  such  chronic  states  of  irritation  of  the  central 
organs — as  in  acute  tetanus.    In  the  central  organs  themselves  there  may 

1  '  Essai  medico-legal  sur  les  diverses  especes  de  Folie,  etc'    Strasb.,  1883. 

^  Compare  the  115  cases  of  Lallemand  ('  Des  Pertes  semmales,'  Paris,  1836- 
42).  It  is  astonishing  how.  almost  without  exception,  these  patients  present  a 
change  of  their  psychical  condition  in  the  direction  I  have  here  indicated. 

^  Lotze,  '  Allgem.  Pathologic.' 


THE    CAUSES    OF    INSANITY.  113 

also  exist  localized  inflammations,  and  caiases  of  the  disease  which  evade 
anatomical  demonstration,  but  from  which  we  may  approximately  ascer- 
tain the  seat,  perhaps,  througli  the  sensibility  of  certain  parts  of  the 
spine,  headache  (affection  of  the  flfth  pair  of  nerves),  etc. 

In  like  manner,  those  depressing  mental  impressions,  shock,  grief, 
etc.,  which  are  so  frequently  met  with  as  causes  of  the  nervous  constitu- 
tion, act  by  provoking  a  violent  irritation,  instantaneous  or  persistent,  of 
a  more  or  less  considerable  portion  of  the  brain — if,  indeed,  they  have 
not  already  (see  §  99)  indirectly  produced  a  secondary  cerebral  affection. 

The  cases  are  proportionately  rare,  but  cannot  be  questioned,  wliere 
such  mental  anomalies,  after  being  developed,  pass  slowly  and  gradually 
without  further  appreciable  injurious  influence  into  actual  insanity. 
Much  more  commonly  the  nervous  constitution  is  but  a  predisposing  cir- 
cumstance, besides  which  something  else  is  necessary — a  real  cause,  either 
a  physical  disease  or  a  moral  influence — in  order  that  the  simple  disposi- 
tion may  become  actual  disorder — that  the  moderate  mental  aberration 
may  pass  into  profound  insanity,  may  become  an  actual  cerebral  disease. 

After  what  has  been  said  in  the  two  preceding  paragraphs,  we  may  dispense 
with  the  further  discussion  of  the  so-called  temperaments  in  so  far  as  they  dis- 
pose to  mental  diseases.  In  common  with  many  esteemed  investigators  (Gall, 
Georget,  Lotze,  etc.),  we  cannot  accord  any  real  importance  to  those  four  classes 
of  temperaments  taken  from  the  ancient  humeral  pathology — a  division  which 
can  scarcely  be  adhered  to,  as  it  has  never  been  empirically  proved  and  is  of  lit- 
tle practical  use. 

Besides  the  circumstances  wliich  have  been  spoken  of,  there  are  still  a  number 
of  serious  chronic  diseases  whicli  ought  to  be  considered  as  bodily  predisposing 
causes.  As  has  been  already  remarked,  mental  diseases  originate  under  the 
influence  of  several  unfavorable  co-operating  causes,  that,  in  certain  cases,  such 
a  cerebral  disease  may  appear  under  the  influence  of  cei'tain  given  circumstances 
which  may  be  traced  to  the  previous  detei'ioration  of  the  general  health  incon- 
sequence of  chronic  disease  in  some  other  organ.  We  must  be  careful,  however, 
not  to  assume  the  existence  of  severe  chronic  general  diseases  merely  fi"om  cer- 
tain slight  or  obscure  symptoms,  and  in  the  absence  of  necessary  pathological 
proof,  because  such  assumptions  frequently  lead  to  superfluous  and  even  violent 
treatment.  To  enumerate  all  these  diseases  would  be  to  repeat  the  entire  special 
pathology.  The  most  important  of  them  will  be  considered,  and  their  mode  of 
action  in  the  production  of  insanity  pointed  out,  in  tlie  chapter  on  Physical 
Causes.  At  present,  we  shall  merely  once  more  call  to  mind  the  intimate  relation 
which  exists  between  the  predisposing  circumstances  and  those  which,  strictly 
speaking,  are  circumstances  of  causation. 

That  a  formerly  existing  insanity,  though  now  removed,  predisposes  to  a 
retuni  of  the  disease,  need  not  be  further  discussed.  Concerning  relapse,  see  the 
chapter  on  Px'ognosis. 

8 


114  THE   CAUSES   OF   INSANYIY, 


CHAPTER  III. 
THE  CAUSES  OF  INSANITY  (CONTINUED). 

Sectiok  I. — Mode  of  Action  of  Causes. 

§  97.  Although  in  the  majority  of  cases  mental  diseases  are  pro- 
duced by  the  co-operation  of  several,  it  may  be  of  many,  unfavorable 
circumstances,  there  are,  however,  ordinarily  several  amongst  these  cir- 
cumstances which  appear  so  especially  important  and  effectual  as  to  merit 
the  designation   of   special  causes;  or,  in  other  words,  cases  of  illness 
present  themselves  which  can  only  be  ascribed  to  the  influence  of  a  sin- 
gle  unfavorable   relation.       In  the  discussion  of    these  more   intimate 
causes,  we  have  to  consider,  on  the  one  hand,  certain  external  injuries; 
on  the  other,  the  adverse  influence  of  health-destroying  habits;  and, 
again  certain  abnormal  organic  states  which  can  be  the  immediate  cause 
of  such  diseases  of  the  brain.     It  would,  indeed,  be  impossible  to  state 
with  absolute  certainty  the  mode  in  which  all  these  causes  act;  but  if, 
on  the  one  hand,  we  consider  the  nature  of  the  causes  as  they  are  men- 
tioned further  on,  and,  on  the  other,  the  comparatively  little  which  is 
known  regarding  the  special  lesion  of  the  brain  in  insanity— moreover, 
if  we  compare  with  these  two  series  of  facts  which  we  learn  by  observa- 
tion of  the  patients  during  the  period  when  the  causes  act  on  them,  Ave 
will,  with  our  present  knowledge  and  comprehension,  arrive  at  the  fol- 
lowing conclusions: — In  many  cases  the  cerebral  affection  in  insanity  is 
not  palpable;  it  depends  either  on  simple  nervous  irritation,  or  on  slight 
changes  of  nutrition  which  as  yet  cannot  be  more  definitely  defined. 
Often,  then,  the  causes  of  insanity  must  act  in  such  a  manner  that  even 
such  impalpable  cerebral  disorders  can  be  proved.     In  many  other  cases, 
insanity  is  a  symptom  of  cerebral  disease,  of  which  we  do  not  yet  know 
the  minute  anatomical  changes  of  the  first  stage,  but  which,  at  a  later 
period,  leads  to  atrophy  of  the  brain,  to  chronic  hydrocephalus:  these 
must  be  disorders  of  nutrition,  whose  inflammatory  nature  is  at  least  doubt- 
ful.    In  others,  however,  insanity  really  depends  on  fixed  inflammatory 
processes  in  the  cranial  cavity,  which  are  known  to  us  as  well  in  the 
early  stages  as  in  their  results.     Finally,  disorders  of   the  circulation 
within  the  cranium  appear  to  play  an  important  part  in  the  origin  of 
insanity:  in  the  one  case  there  is  anaemia  (originating  in  various  ways — 
see  further  on);  in  the  other,  hypersemia  of  the  brain;  and,  lastly,  kin- 
dred states  which  may  exist  as  part  appearances  and  essential  elements 
of  inflammatory  processes,  as  well  as  alone  and  independent  of  any  inflam- 
matory state. 

We  can  in  general  trace  the  influence  of  the  causes  of  insanity  on  the 
origin  of  these  various  categories  of  morbid  events,  but  we  will  be  com- 
pelled to  confess  that  this  gives  us  but  a  limited  view  of  the  special 
mode  of  action  of  the  causes  generally,  and  that  there  are  only  a  few 


THE    CAUSES    OF    INSANITY.  115 

of  these  causes  ot  which  we  know  with  special  certainty  the  mode  in 
whicli  they  produce  sucli  changes  of  the  brain  as  have  been  enumerated 
in  disease.  It  is  the  same  here  as  in  other  pathology,  where,  as  a  rule, 
the  mediators  between  the  causes  on  the  one  hand  and  the  effects  on  the 
other  are  always  what  we  know  least  about. 

I  cannot  now  attribute  so  much  importance  to  the  hypergemias  within  the 
cranium,  as  I  did  in  the  first  edition  of  this  work;  although,  since  its  publication, 
experienced  medical  psychologists  have  assented  to  the  opinion  there  stated. 
But  neither  should  the  hypersemias  be  undervalued  as  pathogenetic  circumstan- 
ces, to  which  at  present  there  exists  too  great  an  inclination  in  German  medicine. 
It  is  very  evident  that,  in  many  cases,  active  cerebral  congestions  precede  and 
accompany  the  pai'oxysms;  for  example,  of  mania,  of  melancholia,  of  hysteria; 
these  congestions  can  naturally  also  present  themselves  in  quite  anaemic  individ- 
uals. Hypersemia  of  the  brain,  which  can  scarcely  be  considered  entirely  as  a 
post-mortem  phenomenon,  is  an  anatomical  condition  very  commonly  observed 
in  recent  cases  of  insanity  :  stagnation,  slowness  of  the  circulation,  with  conse- 
quent more  venous  congestion,  may  result  -from  diminished  cai'diac  ,power, 
from  organic  changes  in  the  cerebral  arteries.  Mechanical  stasis  in  the  veins 
not  unfrequently  shows  itself  in  recent  cases  of  disease,  at  least  in  the  counten- 
ance by  a  general  slight  cyanotic  livid  color,  dark  color  of  the  neighborhood  of 
the  eyes  and  point  of  the  nose,  redness,  and  sometimes  even  ecchymosis  of  the 
conjunctiva,  prominence  of  the  veins  of  the  temple,  neck,  etc.  The  cause  of 
this  congestion  of  the  venous  system  may  be  heart-disease,  functional  weakness 
of  the  left  heart,  in  overfulness  of  the  right  heart,  resulting  from  prolonged 
incomplete  respiration.  The  depressing  emotions  when  long-continued,  grief  or 
anxiety,  may,  it  appears,  in  this  way  cause  slowness  of  the  respiration,  through 
which  the  lesser  circulation  is  retarded,  and  venous  congestion  follows. 

In  the  same  manner  may  be  explained  the  oppression  felt  at  the  chest  (sighing) 
and  the  smallness  of  the  pulse,  the  tendency  of  the  extremities  to  become  cold, 
the  dark  appearance  of  the  countenance,  the  gray  circles  round  the  eyes  obsei-ved 
in  individuals  so  affected.  But  these  emotions  have  still  other  and  not  less 
important  effects,  of  which  impairment  of  the  general  nutrition,  sleeplessness, 
and  diminution  of  the  blood-forming  powers  are  the  chief. 

We  do  not  believe  that  general  simple  hypereemia  of  the  brain  alone,  without 
the  co-operation  of  other  more  essential,  especially  predisposing  circumstances, 
causes  mental  disease.  We  must  admit,  on  the  other  hand,  that  when  these 
circumstances  exist,  this  condition  co-operates  to  a  great  extent  in  the  produc- 
tion of  the  disease. 

Where  well-marked  and  general  plethora  exists,  the  congestive  states  in  the 
period  of  their  first  commencement,  or  in  more  transitory  mental  disorders, 
may  justify  the  abstraction  of  blood.  A  plethoric  young  man,  who  had  high 
hopes  of  obtaining  a  situation,  was  taken  on  probation ;  his  services,  however, 
were  not  accepted.  He  learnt  the  result  at  night ;  till  then  he  had  been  quite 
well  and  cheerful,  but  all  at  once  he  fell  into  a  state  of  great  depression  ;  he 
passed  a  sleepless  night— he  could  not  remain  in  bed,  but  spent  the  greater 
part  of  the  night  sitting  at  an  open  window.  Slight  delirium,  in  which  he 
imagined  he  was  hunting,  set  in ;  soon  violent  headache  and  general  illness 
came  on. 

Next  morning,  the  whole  head  was  of  a  dark-red  color  and  very  hot  ;  the  eyes 
injected,  the  pulse  small,  quick,  and  very  irregular;  there  was  also  violent  head- 
ache, great  agitation,  foul  tongue,  and  inclination  to  vomit.  Patient  bled  to  one 
pound.  This  was  immediately  followed  by  rapid  improvement  of  all  the  symp- 
toms ;  the  patient  declared  that,  after  the  bleeding,  things  suddenly  ceased  to 
have  the  heavy  and  sad  appearance  which  they  formerly  wore,  and  that  he  could 
profit  by  advice.  In  the  afternoon,  epistaxis  spontaneously  set  in,  which  was  fol- 
lowed by  complete  recovery. 

Section  II. — Psychical  Causes, 

§  98.  We  have  now  to  discuss  in  detail  the  principal  immediate  causes 
of  mental  diseases.  They  are  so  numerous — their  mode  of  action,  of 
which  often  little  is  known,  is  so  various,  that  it  is  impossible  to  form 


116  THE    CAUSES    OF    INSANITY. 

a  logical  classification  of  them;  therefore  we  will  merely  arrange  them 
in  groups  according  to  their  importance  and  significance. 

The  psychical  causes  are,  in  our  opinion,  the  most  frequent  and  the 
most  fertile  sources  of  insanity,  as  well  in  regard  to  preparation  as  espe- 
cially and  principally  the  immediate  excitation  of  the  disease.  We  rec- 
ognize, meanwhile,  that  this  view  rests  not  only  on  statistics,'  but  also 
on  the  collective  impression  of  many  observations;  but  if  we  could  fully 
appreciate  the  psychical  causes,  which  are  often  concealed  in  their  most 
important  details,  this  impression  would  probably  be  a  still  stronger  one. 

Under  psychical  causes,  we  are  before  all  to  understand  former  pas- 
sionate and  emotional  states.  It  is  an  absolute  fact  that  intellectual 
exertion,  unaccompanied  by  emotional  excitement  or  other  further 
powerful  causes  (for  example,  all  kinds  of  excesses,  sleeplessness,  arti- 
ficial excitation  by  excitants),  leads  only  in  the  rarest  cases  to  insanity. 

The  contrary  is  undoubtedly  the  case  with  the  continuous  or  violent 
emotions,  of  which  disagreeable^  adverse,  or  depressive  states  of  emotion 
merit  special  attention;  while  immoderate  joy  alone  has  handed  over  to 
the  asylums  very  few,  if  any,  patients.  Pinel,  that  model  medical 
psychologist  for  all  times,  was  so  convinced  of  the  truth  of  this,  that  the 
first  question  which  he  addressed  to  a  new  patient  was  always,  "Have  you 
suffered  vexation,  grief,  or  reverse  of  fortune?'"  and  nowadays  it  is  quite 
as  rare  as  it  was  then  to  receive  a  negative  answer  to  this  question.  In 
individual  cases  these  painful  emotional  states  may  vary  very  much  in 
their  nature  and  in  their  causes:  sometimes  it  is  sudden  anger — shock'  or 
grief  excited  by  injury,  loss  of  fortune,  a  rude  interference  witii  the  mod- 
esty, a  sudden  death,  etc. ;  sometimes  it  is  the  result  of  the  slow  gnavvings  of 
disappointed  ambition  on  the  mind,  regret  on  account  of  certain  unjust 
actions,  domestic  affliction,  unfortunate  love,  jealousy,  error,  forced  so- 
journ in  inadequate  circumstances,  or  any  other  injured  sentiment.  In 
every  case  there  are  influences  which,  through  intense  disturbance  of  the 
mass  of  ideas  of  the  ego,  cause  a  mournful  division  in  consciousness,  and 
we  always  see  the  most  powerful  effects  where  the  wishes  and  hopes  have 
been  for  a  lon^  time  concentrated  upon  a  certain  object.  Where  the 
individual  has  made  certain  things  indispensable  to  his  life,  and  when 
these  are  forcibly  withdrawn,  the  passage  of  the  ideas  into  efforts  is  cut 
off,  and  accordingly  a  gap  in  the  ego  and  a  violent  internal  strife  results. 

The  effect  of  these  emotions  in  the  production  of  insanity  is  to  be  judged  of 
according  to  the  strength  of  the  first  shock,  according  to  its  longer  or  shorter 
duration,  but  more  especially  according  to  the  present  mental  disposition  of  the 
patient.  Then,  again,  the  degree  of  violence  of  the  first  impression,  its  more 
rapid  cessation  or  orolonged  reverberation,  depends  to  a  great  extent  on  this  dis- 
position. In  many  cases,  the  fact  that  such  long  and  violent  states  of  passion  or 
ill-humor  could  arise  is  of  itself  a  sign  of  this  (already  spoken  of  in  g  95)  psychical 


1  We  could  quote  many  statistics  in  favor  of  this  view,  especially  the  state- 
ments of  Parchappe  and  Brierre  de  Boismont,  in  opposition  to  the  calculations  of 
Moreau  ('Comptes  rendus,'  xvii.,  1843,  pp.  134,  279).  We  consider,  however, 
for  the  reasons  stated  in  §  63-64,  that  it  is  impossible  to  solve  this  question  by 
statistics  alone ;  still  it  may  be  mentioned  that  Guislain  also  ('  Legons  orales,' 
ii.,  1852,  p.  44),  found  moral  causes  to  exist  in  66  out  of  100  cases;  which  quite 
coincides  with  the  figures  given  by  Guislain— 67,  and  Hare  66  per  cent. 

2  Georget,  '  De  la  Folic,'  Paris,  1820,  p.  160. 

3  See  two  examples  of  insanity  caused  bv  violent  shock,  by  Ellis  ('  Traite,'  etc., 
trad.  p.  Archambault,  Paris,  1840,  pp.  108,  109).  Ellis  here  ascribes  the  effect  to 
the  altered  cardiac  activity.  Guislain  found,  amongst  100  patients  who  were 
admitted  in  the  course  of  a  year,  shock  or  anxiety  to  be  the  cause  of  the  insanity 
in  nine  instances. 


THE    CAUSES    OF    INSANITY.  117 

peculiarity;  and  it  was  the  special  original  irritability  and  passionateness  of  the 
individual— tlie  already  existing  disposition  to  emotions,  and  to  sudden  dimming 
of  the  consciousness,  which  from  a  period  dating  even  from  the  years  of  child- 
hood could  often  be  pointed  to  as  the  source  of  mental  sickness,  often  as  the  cause 
of  the  subsequent  habits  and  actions  of  the  iDatient.  This  disposition  may  be 
manifested  by  disorderly  conduct,  idleness,  desire  for  fashionable  follies,  love  of 
pleasure,  and  political  extravagance;  or  by  religious  enthusiasm  and  asceticism, 
by  misplaced  friendship  and  love;  and,  finally,  by  the  moral  bankruptcy  of  a  life 
lavished  in  follies.  On  the  form  which  the  emotion  receives  from  the  external 
causes,  very  little  rarely  depends:  each  I'ace,  each  position  in  life,  each  individual 
receives  liis  mental  wounds  in  that  sphere  which  nature  and  external  circum- 
stances have  provided  for  him;  and,  moreover,  each  has  a  point  on  which  he  is 
most  vulnerable,  another  sphere  from  which  violent  shocks  most  easily  proceed:  in 
one  it  is  money,  in  another  the  estimation  in  which  he  is  held  by  others;  in  the 
third,  his  feelings,  his  faith,  his  knowledge,  his  family,  etc.  But  the  emotions 
and  passions  are  not  the  only  precursors  of  insanity;  the  state  of  exhaustion  of 
the  sensibility  wdiich  they  produce  is  also  a  very  frequent  cause.  Where  there 
is  no  strong  intelligence  to  govern  the  illusions,  the  mental  coldness  and  want  of 
interest— where  everything  seems  cold  and  stale,  the  heart  benumbed,  the  world 
become  emptj- — these  mental  states  very  coutmonly  end  in  melancholia,  suicide, 
or  profound  insanity. 

Although,  in  general,  it  is  chiefly  the  long,  continuous  emotions  which  have 
a  powerful  influence  on  the  production  of  mental  disorders,  there  are  also  cases 
where  an  attack  of  insanity,  especially  of  mania,  immediately  follows  a  single 
outburst  of  violent  anger  or  rage:  such  cases,  also  interesting  in  a  forensical 
point  of  view,  frequently  occur  under  tlie  co-operating  influence  of  spirituous 
liquors,  even  when  they  have  been  taken  in  very  small  quantity.  This  would 
not  be  likely  to  occur  in  any  but  those  who  are  strongly  predisposed. 

§  99.  The  mode  of  action  of  these  psychical  causes  is  either  direct  or 
indirect. 

In  the  first  case,  the  emotions,  particularly  the  passed-off  psychical 
phenomena,  are  the  immediate  originators  of  the  mental  disease,  inasmuch 
as  they  produce  a  state  of  intense  irritation  of  the  brain,  which  now  con- 
tinues. 

Thus,  for  example,  fright,  which  is  so  dangerous  to  the  female  organi- 
zation, may  immediately  give  rise  to  an  insanity  which  for  years  may 
present  the  chief  character  of  the  physiological  effects  of  fear — that  half 
convulsive,  half  paralytic  state  of  torpor,  of  thought,  and  will.'  At  other 
times  we  see  long-continued  moderate  psychical  perversion,  persistent 
anger,  grief,  anxiety,  owing  to  direct  excessive  irritation  of  the  brain, 
gradually  increase  and  pass  immediately  'nto  the  first  stage  of  insanity 
which  very  often  presents  the  special  character  of  these  kinds  of  psychical 
pain. 

Here  also  (according  to  the  preceding  section)  it  is  often  difficult  to 
distinguish  early  mental  predisposition  from  more  immediate  psychical 
causes.  Those  causes  may  also  here  be  mentioned,  in  which  mental  pecu- 
liarities of  long  standing,  which  have  for  a  long  time  gained  for  the 
individual  the  title  of  a  half-foolish,  crotchetty  candidate  for  the  mad- 
house, gradually  pass  without  further  appreciable  cause  into  actual  in- 
sanity. 

More  frequently,  however,  the  insanity  originates  indirectly — through 
the  medium  of  a  pathological  process — from  the  psychical  causes,  inas- 
much as  they,  in  the  first  place,  bring  about  further  deviations  from  the 
normal  organic  processes  in  other  parts,  from  which  then  the  cerebral 

'  We  may  call  to  mind  the  similar  sudden  effect  of  shock  in  the  production  of 
epileptic  attacks.  Anger  may  act  quite  as  suddenly.  In  these  cases  a  very  rapid 
and  intense  change  in  the  collective  activity  of  the  brain  takes  place,  which 
appears  to  act  very  injuriously  upon  that  organ. 


118  THE    CAUSES    OF    LNSANITY, 

disease  proceeds  as  a  secondary  result.  If  we  consider  the  fact  previously 
spoken  of,  that  the  emotions  ordinarily  disturb  sympathetically  the  func- 
tions of  the  organs  of  circulation,  respiration,  digestion,  and  of  blood 
formation,  we  will  easily  understand  how  these,  when  long  continued  or 
very  violent,  must  cause  slight  disorders  of  these  functions,  and  those 
individuals  are  most  easily  affected  in  whom  (owing  to  congenital  or  ac- 
quired disposition)  emotions  are  most  easily  excited. 

Very  frequently  the  cerebral  disease  only  commences  when,  after  long 
oscillations,  some  serious  pathological  change  has  gradually  arisen  in  some 
other  organ. 

It  is  by  no  means  rare,  for  example,  after  some  untoward  event  which 
immediately  caused  disturbance  of  the  cerebral  processes,  to  see  the  indi- 
vidual become  again  mentally  quiet;  but  he  begins  to  feel  ill,  to  suffer  in 
various  other  organs,  and  it  is  only  after  years  of  constantly  increasing 
deterioration  of  the  constitution,  owing  to  the  development  of  anaemia  or 
other  chronic  disease,  that  mental  disease  is  established.  These  effects  are 
particularly  evident  in  states  of  continued  buc  carefully  concealed  mental 
pain:  those  tears  which  have  been  long  restrained  and  concealed  with 
smiles  or  pride,  or  falsehood,  show  themselves  almost  unfailingly  in  the 
development  of  chronic  diseases  which  secondarily  give  rise  to  a  cerebral 
affection.  We  see  that  under  such  circumstances  the  individual  soon 
becomes  emaciated,  digestion  suffers,  and  the  intestinal  functions  become 
weak;  that  sleeplessness,  palpitation,  cough,  all  kinds  of  anomalies  of 
sensibility,  cerebral  congestion,  nervousness  and  hypochondria,  establish 
themselves.  In  the  female  sex,  menostosia  or  irregularity  of  the  periods, 
angemia,  neuralgias,  and  the  group  of  symptoms  of  hysteria  appear. 

We  see  that,  under  the  influences  of  such  circumstances,  dispositions 
to  disease  which  had  hitherto  been  dormant — tuberculosis,  chronic  heart 
diseases,  etc. — are  now  awakened  or  rapidly  aggravated,  and  that  out  of 
these  pathological  mediators  between  first  causes  and  ultimate  results, 
mental  diseases  proper  are  finally  established. 

A  mediator  of  this  description  of  especial  importance  and  frequency 
in  connection  with  mental  diseases  is  continned  sleepless /less,  which  often 
accompanies  the  depressing  emotions,  which  overexcites  the  brain,  and 
lowers  the  nutrition.  It  presents,  therefore,  in  the  preliminary  stages  of 
insanity,  a  symptom  which  may  be  often  effectually  combated  by  thera- 
peutic measures. 

Most  of  the  relations  spoken  of  in  this  section  are  explicable  through  the  influ- 
ence of  the  nervous  centres  on  the  whole  economy;  and  it  is  easily  comprehen- 
sible that  these  consequences  of  the  emotions  are  most  frequent  and  most  dan- 
gerous in  the  period  of  life  in  which  the  organism  is  subjected  to  the  greatest 
expenditure  of  force  in  order  to  its  proper  development  and  further  growth,  and 
in  which  it  generally  is  most  capable  of  disease,  viz.,  at  the  period  of  puberty, 
during  pregnancy,  childbirth,  the  climacteric  period,  etc. 

The  cause  of  the  depressing  emotions,  the  groups  of  ideas  around  which  it 
revolves,  exercise  frequently  (but  not  always,  much  more  decided  in  the  minority 
of  cases)  a  deciding  influence  on  the  subject  of  the  insane  ideas.  Thus,  after  the 
loss  of  a  loved  relative,  the  delirium  will  long  revolve  around  those  ideas  which 
have  relation  to  this  loss— a  relation  which  coincides  to  a  certain  extent  with 
that  mentioned  above.  In  these  cases  the  boundary  betwixt  the  physiological 
state  of  emotion  and  insanitv  is  often  difficult  to  trace.  At  least,  it  may  demand 
profound  consideration;  the"  latter  may  appear  as  the  immediate  continuation  of 
a  physiological  state  of  the  established  emotion. 

The  essential  difference  between  the  two,  therefore— between  melancholia  and 
a  gloomy  disposition— consists  in  this,  that  in  the  former  the  patient  cannot 
withdraw  himself  from  his  ill-humor,  because  it  has  become  fixed  through  the 
mediation  of  abnormal  organic  phenomena:  these  latter  may  in  certain  circum- 
stances be  very  important  in  regard  to  diagnosis. 


THE    CAUSES    OF    INSANITY.  119 

Besides  this  regulating  influence  of  the  cause  of  the  depressing  emotions  on 
the  subject  of  the  delirium,  there  are  certain  definite  moral  causes,  which  give 
(but  not  always)  also  a  peculiar  character  to  the  insanity.  Thus,  the  insanity 
observed  in  women  after  disappointment  in  love  is  characterized  generally  by  a 
deep  melancholic  depression,  occasionally  passing  into  stupor;  by  a  tendency  to 
suicide  by  hysterical  complications,  great  bodily  enervation,  frequent  termination 
In  tuberculosis.  Insanity  from  fright  most  commonly  presents  the  character  of 
•sTielancholia  with  stupor,  with  or  without  consequent  mania,  etc. 

Section  III. — Mixed  Causes. 

§  100.  1.  DrunTcenness  stands  midway  between  the  psychical  and  the 
physical  causes  ;  its  effects  are  very  powerful  as  well  as  very  complex. 
On  the  one  hand,  the  action  of  alcoholic  excesses  is  principally  purely 
physical — in  part  direct,  by  causing  irritation  and  changes  in  the  nutri- 
tion of  the  brain,  by  the  development  of  chronic  stasis  within  the  cra- 
nium ;  in  part  indirect,  by  producing  drunkard's  scorbutus,  fatty  degen- 
eration of  the  liver,  serious  gastric  diseases  ;  in  short,  by  complete  ruin 
of  the  constitution.  But,  on  the  other  hand,  drunkenness  produces  also 
important  psychical  causes — partly  in  those  excitements,  noisy  quarrels 
and  brawls,  which  drunkenness  so  frequently  occasions  ;  partly  in  the  sad 
mental  impressions  which  its  ordinary  consequences — domestic  discom- 
fort, ruin  in  business,  withdrawal  from  the  family  circle,  loss  of  self-respect 
— must  gradually  force  home.  Finally,  as  a  third  cause,  it  is  to  be 
remembered  that  in  many  cases  the  drunkenness  is  not  the  cause,  but  the 
consequence,  of  such  impressions — domestic  sorrow,  grief,  annoyance, 
and  vexation  ;  because  of  which,  relief  and  consolation  are  sought  in 
dissipation.  Under  the  simultaneous  action  of  two  such  powerful  causes, 
insanity  is  generally  very  rapidly  developed. 

That  intoxication,  when  carried  to  a  certain  degree,  as  a  dreamy  condition 
with  numerous  hallucinations  and  illusions,  really  resembles  insanity,  is  easily 
understood.  Sometimes  we  see  individuals  who,  after  partaking  of  a  relatively 
small  quantity  of  spirits,  and  without  being  in  a  state  of  deep  intoxication,  but 
retaining  fully  their  consciousness,  present  a  gi-eat  tendency  to  commit  very 
extravagant,  noisy,  and  foolish  acts;  a  circumstance  which  may  be  truly  con- 
sidered as  a  symptom  of  predisjwsition  to  mental  disease.  Moreover,  there  occur 
in  drunkards  sudden  convulsive  states  which  resemble  epileptic  attacks,  and 
which  are  sometimes  followed  by  a  condition  of  forgetfulness  and  tranquil  delir- 
ium, at  other  times  by  outbreaks  of  furious  delirium,  which  has  been  termed  the 
convulsive  form  of  intoxication. ' 

The  habitual  drunkard,  in  whom  the  habit  is  already  far  advanced,  presents 
also,  even  when  he  is  not  in  a  state  of  intoxication,  many  signs  which  indicate  tlie 
existence  of  an  advancing  chronic  disease  of  the  brain,  and  which  make  him  closely 
resemble  the  mentally  diseased.  Indeed,  this  condition  may  gradually  pass  into 
insanity,  and  particularly  into  dementia;  and  there  are  constantly  found  in  the 
brains  of  habitual  drunkards,  as  in  many  of  the  insane,  the  results  of  passive 
congestion — chronic  opacities  and  thickenings  of  the  cerebral  membranes.  The 
appetite  acquired  by  habit  is  so  powerful  in  the  drunkard,  the  ideas  which  might 
oppose  it  are  so  weak,  and  the  will  has  become  so  paralyzed,  that  he,  even  though 
he  is  aware  that  he  renders  himself  despised  and  contemptible,  undermines  his 
constitution,  disturbs  his  domestic  happiness,  ruins  his  business,  and  every  day 
postpones  the  good  resolution  which  he  perhaps  had  made.  The  craving,  the 
dizziness,  the  dulness  of  the  senses,  the  muscular  feebleness,  the  stomach  com- 
plaints from  which  he  suffers,  are,  each  time  he  partakes,  alleviated  for  the 
moment,  and  it  may,  perhaps,  be  partly  owing  to  the  fact  that  these  disorders 
require  each  day  to  be  remedied  that  drunkenness  is  often  so  inveterate. 

Serious  mental  disorders  may  commence  in  drunkards  in  various  ways. 

'  See  Marc,  '  Die  Geisteskrankheiten,'  ii.,  p.  431;  Drake,  in  Nasse's  '  Zeitschrift 
fiir  Anthropologic,'  1824,  p.  224. 


120  THE    CAUSES    OF    INSANITY. 

Delirium  tremens  attacks  habitual  drunkards,  and  sometimes  also  indivi- 
duals who  are  in  the  habit  of  drinking,  but  who  very  seldom  become 
intoxicated.  Occasionally  it  comes  on  suddenly  ;  generally  it  is  preceded 
by  sleej)lessness,  or  by  disturbed  sleep  from  confused  dreams.  Emotions, 
pains,  acute  diseases  (especially  pneumonia),  haemorrhages,  weakening 
influences  of  any  kind,  sudden  suspension  of  all  alcoholic  drinks,  fre- 
quently determine  the  commencement.  Its  characteristic  symptoms  are 
sleeplessness,  tremor,  tendency  to  perspire,  hallucinations  ;  the  mental 
state  is  generally  that  of  great  restlessness  and  agitation,  chiefly  depend- 
ing on  the  hallucinations — therefore  in  certain  cirewmstances  the  patient 
may  become  dangerous  to  those  surrounding  him. 

Of  all  the  various  forms  of  chronic  insanity,  drunkenness  especially 
appears  to  possess  much  in  common  with  general  paralysis.  Besides, 
incompletely  developed  forms,  which  in  a  medico-legal  point  of  view  are 
often  very  difficult  to  judge  of,  are  very  common.  These  slight  chronic 
mental  anomalies  observed  in  the  drunkard  are  manifested  by  very  appa- 
rent mental  dulness,  loss  of  the  sense  of  duty,  and  in  general  of  all  the 
higher  sentiments  ;  conscience  and  the  sense  of  truth  are  blunted  ;  the 
intellect  is  generally  enfeebled,  especially  the  memory  :  frequently  slight 
or  well-marked  hallucinations  also  exist.  Numerous  other  anomalies  of 
the  nervous  system  also  present  themselves — tremors  of  the  hands  and 
of  the  tongue,  deadening  of  the  sense  of  sight  iind  o"f  touch,  debility  of 
the  genital  organs  ;  the  patient  has  formication  and  cram])s  in  the  limbs, 
giddiness,  sometimes  epileptic  attacks  of  greater  or  less  severity  ;  sooner 
or  later  marasmus  and  dropsy  may  set  in,  with  the  usual  local  affections 
(gastric  disease,  emphysema,  cirrhosis  of  the  liver,  Bright's  disease,  etc.). 
The  children  of  drunkards  very  frequently  die  early  from  convulsions  ; 
many  of  them  are  idiots,  imbeciles,  or  microcephalic ;  or  in  later  life 
they  present  the  same  disposition  to  drunkenness,  insanity,  and  crime. 

We  cannot  state  generally  to  what  extent  drunkenness  acts  in  the 
production  of  the  mental  diseases  ordinarily  met  with  in  asylums  ;  the 
various  nations  present  in  this  respect  very  great  differences,  and  the 
statistics  which  we  possess  can  be  only  to  a  slight  extent  compared,  because 
delirium  tremens  is  sometimes  included,  sometimes  not.  Amongst  747 
cases,  Halloran  found  drunkenness  given  as  a  cause  in  more  than  \i\\. 
Prichard  and  Esquirol  ascribe  the  half  of  the  attacks  in  England  to 
this  cause.  In  1848,  Webster,  in  Bedlam  (704  cases),  found  this  to  be  a 
cause  in  only  ^th-^tli  of  the  cases ;  Morrison,  in  Bedlam  (1428  cases), 
in  scarcely  -^th,  and  amongst  these  there  are  certainly  included  several 
cases  of  delirium  tremens.  It  is  generally  known  that  in  later  times  the 
abuse  of  spirits  in  England  has  very  much  diminished,  and  this  cause 
has  proj)ortionately  decreased  in  the  etiological  lists  of  the  asylums.  I 
have  been  assured  by  very  competent  authorities  in  England,  that  this 
gratifying  result  is  to  be  attributed,  not  to  temperance  societies,  but  to 
the  influence  of  the  corn  laws.  At  the  present  time  drunkenness  nowhere 
appears  to  be  such  a  powerful  cause  of  mental  disease  as  in  America. 
Rush  gives  this  as  the  cause  in^-d  of  the  cases  in  the  hospitals  of  Penn- 
sylvania, and  later  statistics  of  certain  American  asylums  show  even  a 
larger  proportion.  From  Germany  we  have  important  statistics  by  Jacobi ; 
Bergmann  (for  Hanover,  -^-th)  ;  Dagonet  (1856),  for  Stephansfeld,  gives 
■|^th-4th  of  the  cases  as  the  average. 

Drunkenness  is  naturally  a  more  important  and  frequent  cause  of  insanity  in 
men  than  in  women;  still  there  also  occur  amongst  females,  not  only  of  the  lower 
class — amongst  prostitutes — where,  without  doubt,  this  drunken  mania  is  very 


THE    CAUSES    OF    INSANITY.  121 

frequent — but  also  in  the  higher  classes,  amongst  hysterical  females,  particularly 
during  the  climacteric  period,  examples  of  drunkenness  and  resulting  insanity. 
Sutton  mentions  a  case  where,  in  a  lady,  delirium  tremens  resulted  from  the 
excessive  use  of  tinctv^re  of  lavender  for  sleeplessness. 

Dipsomania,  properly  so  called,  or  periodic  intermittent  dninkenness,  should 
not  be  considered  as  a  cause,  but  rather  a  symptom,  of  periodic  insanity.  Several 
cases  have  been  observed — and  I  myself  know  of  such — in  which  from  time  to 
time,  simultaneously  with  other  nervous  symptoms,  headache,  great  prostration, 
sleeplessness,  nausea,  gnawing  sensation  in  the  epigastric  region,  mental  perver- 
sion, general  discomfort,  and  a  certain  degree  of  melancholy  sets  in,  which,  after 
a  time,  is  succeeded  by  restlessness;  the  patient  begins  to  frequent  the  tavern, 
and  generally  drinks  hard  for  several  days  continuously.  The  drunkenness  in 
these  cases  generally  attains  the  proportions  of  an  actual  maniacal  attack,  from 
which  the  patient  emerges  sometimes  quickly,  sometimes  slowly,  in  a  state  of 
deep  depression,  and  often  retains  for  a  long  time  a  strong  aversion  to  spirits. 
Generally  these  attacks  are  repeated.  In  their  diagnosis  we  have  to  inquire  par- 
ticularly whether  or  not  the  attack  has  been  preceded  by  a  stage  of  melancholia, 
whether  there  be  any  hereditaiy  predisposition,  and  whether  the  ordinary  habits 
of  the  patient  be  those  of  sobriety,  or,  on  the  contrary,  he  exhibits  an  inclination 
to  drunkenness.  In  the  latter  case  it  is  very  problematical  whether  the  attack 
of  dipsomania  be  the  result  of  disease.' 

In  America,  and  also  in  England,  cases  enter  the  asylums  in  which  the  abuse 
of  opmm  seems  to  have  been  the  cause  of  the  insanity;  such  cases  present  also 
the  general  appearances  of  chronic  opium-poisoning.  Tobacco,  wlien  indulged 
in  to  excess,  and  in  some  cases  even  its  moderate  use,  may  considerably  affect  the 
functions  of  the  entire  nervous  sj^stem.  Although  there  seem  to  be  no  facts 
which  might  lead  us  to  suppose  that  tobacco  alone  can  become  a  cause  of  insanity, 
still  it  cannot  be  denied  that  in  many  individuals  with  weak  and  disturbed  mental 
functions  it  may  co-operate  to  this  end.  The  cerebral  affection  which  is  produced 
by  ch  ronic  lead-poisoning  presents  sometimes  many  analogies  to  delirium  tremens, 
particularly  as  in  both  cases  there  is  observed  an  excited  muttering  delirium  with 
tremor;  but  in  lead-poisoning  the  excitement  passes  frequently  into  stupor: 
besides,  there  are  often  cramps  and  paralysis:  tlie  prior  existence  of  lead-colic 
and  the  gray  line  rovmd  the  gums  may  assist  in  forming  the  diagnosis.  Moreau 
(Annal.  Med.  Psychol.,  vii.,  1855,  i).  639)  narrates  a  case  of  stupor  alternating 
with  maniacal  excitement  after  the  extensive  use  of  a  pomade  which  contained 
a  great  quantity  of  lead.  The  disease  commenced  after  the  pomade  had  been  used 
for  fourteen  days.  In  this  case  there  was  also  colic  and  the  gray  coloration  of 
the  gums. 

§  101.  2.  A  complex  action  like  that  of  drunkenness,  influencing  at 
the  same  time  the  mental  and  bodily  health,  results  in  a  life  spent  in 
disquietude  and  tumult,  in  carelessness  and  dissoluteness  ;  we  may  also 
add,  misery  and  privation,  which  are  very  important,  and  frequently  the 
only  appreciable  causes.  How  often  do  we  find  in  the  antecedents  of  the 
insane,  an  irregular  life,  disturbed  by  adventures,  changing  impulses, 
and  peculiar  complication,  full  of  varying  fortunes,  hardships,  misery, 
and  excess — full  of  incidents  such  as  must  afford  fertile  sources  of  con- 
flicts with  the  world,  of  mental  excitement  and  deep  disappointment  ! 
How  often  do  we  see  jnivation  and  poverty  which  lead  to  mental  pain 
and  despondency,  in  which  the  individual  can  no  more  surmount  the 
misery  of  his  position,  can  no  longer  resist  his  misery,  and  falls  into 
melancholy,  suicide,  or  profound  insanity  !  But  there  are  other  influ- 
ences than  those  which  are  directly  mental :  the  bad  nourishment,  hun- 
ger, cold,  fatigue,  and  over-exertion,  which  must  necessarily  accompany 
such  misery,  are  important  physical  causes.  In  all  disorderly  and  irreg- 
ular lives,  Avhether  voluntary  or  compulsory  (as  fatigues  of  military  life, 
in  war,  et,c.),  we  ordinarily  meet  these  two  kinds  of  injurious  influences 
together. 

'  See  Briihl-Cramer,  'Ueber  die  Trunksucht,' etc.,  1819;  Hohnbaum,  "  Ueber 
die  psych.  Behandlung  der  Trunkstichtigen,"  Nasse's  'Zeitschrift  fiir  psych. 
Aerzte,'  1820;  Marc-Ideler,  ii.,  1,  c;  Huss-  '  Alcoholismus  Chronicus.' 


122  THE    CAUSES    OF    INSANITY. 

3.  Sexual  excesses  have  a  similar  dou1)le  injurious  influence,  in  conse- 
quence of  the  mental  excitement  which  is  frequently  associated  therewith, 
and  owing  to  the  physical  exhaustion  which  results.  The  same  may  be 
said  of  onanism,  which  is  likewise  an  important  and  frequent  cause 
of  insanity,  as  of  all  other  physical  and  moral  degradation.  Besides  the 
emission  of  semen,  and  the  direct  action  of  the  often  permanent  irrita- 
tion of  the  genital  organs  on  the  spinal  cord  and  the  brain,  onanism  cer- 
tainly has  a  still  more  injurious  action  on  the  mental  state  and  a  more 
direct  influence  in  the  production  of  insanity.  That  constant  struggle 
against  a  desire  which  is  even  overpowering,  and  to  which  the  individual 
always  in  the  end  succumbs — that  hidden  strife  betwixt  shame,  repent- 
ance, good  intentions,  and  irritation,  which  imperiously  impels  to  the  act, 
we  consider,  after  not  a  little  acquaintance  with  onanists,  to  be  by  far 
more  important  than  the  primary,  direct  physical  effect.  The  share 
which  each  mode  of  action  exerts  cannot  be  distinguished  in  individual 
cases;  but,  generally  speaking,  the  effect  of  onanism  seems  to  be  greater 
in  proportion  to  the  earliness  of  the  age  at  which  the  constitution  is  in- 
jured and  the  patient  becomes  markedly  anaemic,  the  degree  in  which  it 
is  accompanied  by  those  painful  emotions,  and  in  which  it  becomes  the 
cause  of  local  disease  of  the  genital  organs  (see  §  108).  When  these  three 
influences  fail,  masturbation  is  seldom  followed  by  serious  consequences. 

Ellis  ('  Traite  de  rAlienation,'  p.  133)  ascribes  the  majority  of  all  the  cases 
treated  in  public  asylums  to  onanism.  Others,  as  Guislain  and  Parchappe,  in 
their  etiological  tables,  attribute  to  this  cause  but  a  small  proportion.  Compare 
the  treatise  on  the  relations  of  self-abuse  as  a  cause  of  insanity  in  Jacobl  and 
Nasse  (' Zeitschrift,' i.,  1835,  p.  205).  Ellinger  (■  Zeitschrift  fiir  Psychiatrie,' ii., 
1845,  p.  22)  considers,  from  careful  observation  in  Winnenthal,  that  onanism  is  a 
co-operating  influence  in  one-fifth  of  the  cases.  See  Nasse,  ibid.,  1849,  p.  869; 
Claude,  '  Revue  Medicale,'  1849,  Mai,  p.  252. 

In  this  series  of  causes  we  must  carefully  avoid  confusion.  It  is  not  at  all 
rare  to  see  at  the  commencement  of  insanity  (or  rather  at  the  stage  of  transition 
of  a  moderate  degree  of  melancholia  into  mania)  the  patient  exhibits  an  increased 
sexual  instinct  which  may  lead  to  onanism  or  to  frequenting  bad  houses.  In  this 
we  recognize,  not  a  cause,  but  a  symptom  of  mental  disease.  In  many  cases 
where  the  sexual  excesses  really  at  the  time  appear  to  be  causes  of  the  insanity,  they 
are  only  the  immediate  consequences  of  a  morbid  irritation,  of  an  excitation  of 
long  standing  of  certain  portions  of  the  nervous  system.  In  particular,  onanism 
spontaneously  commencing  in  early  life,  long  before  puberty,  may  almost  with 
absolute  certainty  be  ascribed  to  morbid  irritation  of  the  genital  organs,  which 
coincides  with  the  entire  nervous  constitution  and  with  a  predisposition  to  mental 
disease. 

The  mental  disorders  which  originate  under  the  influence  of  onanism  have  no 
constant  specific  character,  but  they  in  the  majority  of  cases  betray  themselves 
by  profound  dulness  of  sentiment  and  mental  exhaustion,  by  hallucinations  of 
hearing,  by  a  religious  character  of  the  delirium,  by  a  rapid  transition  to  demen- 
tia, and  consequent  frequent  incurability. 

Section  IV. — Physical  Cmcses. 

§  102.  As  we  do  not  consider  it  possible  that  (see  §§  79  and  98)  the 
question  whether  insanity  originates  more  frequently  from  psychical  or 
from  somatic  causes  can  be  solved  by  statistics  alone,  any  discussion  of 
the  statistics  relating  to  this  subject,  from  the  days  of  Pinel  to  the  pres- 
ent time,  may  be  dispensed  with,  in  that  the  reader  in  regard  to  the 
investigations  on  this  subject  is  referred  to  the  old  discussion  jvhich  has 
been  carried  on  between  Moreau  de  Jonnes  on  the  one  hand,  and  Par- 
chappe and  Brierre  on  the  other,'  with  the  remembrance  that  all  such 

'  '  Comptes  rendus  de  I'Academie  des  Sciences,'  xvii.,  1843. 


THE    CAUSES    OF    INSANITY.  123 

tables  afford  results  inadmissible  and  unreal,  according  as  the  individual 
titles  are  vague  and  abstract, '  and  idiocy  less  carefully  separated  from  the 
other  mental  diseases/  It  is  evident  that  in  many  cases  insanity  may 
originate  from  purely  physical  causes;  that,  on  the  other  hand,  under 
tlieir  co-operation,  psychical  causes  lead  more  rapidly  and  more  markedly 
to  the  production  of  mental  disease.  A  hereditary  or  acquired  disposi- 
tion may  frequently,  though  not  invariably,  be  made  out;  it  often  mani- 
fests itself,  besides  the  symptoms  we  have  already  mentioned,  by  the  easy 
origin  of  delirium  in  acute  diseases,  even  though  of  but  slight  intensity. 
In  such  individuals,  in  different  degrees,  any  serious  bodily  disease  may, 
through  secondary  affection  of  the  brain,  become  a  cause  of  insanity:  on 
the  other  hand,  however,  somatic  causes  do  not  only  act  in  this  way  by 
exciting  disease  in  those  already  predisposed,  but  by  them  dispositions 
are  originated  which  afterwards,  under  the  influence  of  moral  causes, 
pass  into  insanity. 

These  physical  causes  consist  partly  in  conditions  which,  although 
still  physiological,  expose  the  patient  more  to  disease  (as  childbed),  partly 
in  already  developed  acute,  or  to  a  greater  extent  in  chronic  diseases  {e.  g., 
tuberculosis) — partly  in  certain  external  injuries  {e.  g.,  injury  of  the 
head).  In  their  enumeration  we  shall  commence  with  those  which  act 
directly  on  the  nervous  system. 

§  103.  1.  Insanity  originating  from  other  nervons  diseases. — Most 
diseases  of  the  brain,  even  althougli  they  do  not  at  first  present  the 
characters  of  mental  diseases,  may  in  their  further  course  become  such. 
Acute  meningitis  can  only,  when  it  has  become  chronic — that  is,  through 
the  metamorphoses,  and  the  other  results  of  the  exudation — be  immedi- 
ately recognized  as  a  mental  disease.  The  various  affections  of  the  brain 
which  may  give  rise  to  epilejjsy  are  sometimes  connected  from  the  first 
Avith  decided  mental  disturbance — intermitting  attacks  of  the  former  may 
even  precede  the  intermittent  convulsions — sometimes  it  is  only  after  the 
epilepsy  has  existed  for  a  long  time  that  those  morbid  processes  can 
become  the  originators  of  mental  disease'  (either  because  the  affection — e. 
g.,  chronic  inflammation— originally  situated  in  the  interior  of  the  brain, 
extends  to  the  surface,  or  through  consecutive  atrophy  of  the  brain,  etc.). 
It  is  the  same  witli  apoplexy:  it  can,  besides  the  paralysis,  be  followed  by 
an  insanity  (almost  always  in  the  form  of  dementia — sometimes,  however, 
of  mania)  which  is  sometimes  primary,  existing  from  the  commencement 
— sometimes  secondary,  owing  to  those  degenerations  which  apoplexy 
gives  rise  to  within  the  brain.  Sometimes  the  mental  disorder  is  very 
limited,  affecting  only  certain  series  of  ideas:  it  may,  however,  extend  to 
general  and  profound  mental  weakness. 

All  severe  injuries  to  the  head  are  acknowledged  to  be  of  great  import- 
ance in  the  production  of  insanity,  whether  they  consist  of  fracture  of 
the  skull,  extravasation  of  blood,  loss  of  cerebral  substance,  or  simple 
concussion.  While  in  the  most  severe  of  these  cases  the  resulting  men- 
tal disturbance  (dementia,  dementia  with  mania,  etc.)  generally  appears 
at  once  or  on  recovery  from  the  injury,  in  other  cases  it  does  not  appear 
till  much  later — one,  two,  six,  or  even  ten  years  after  the  accident.  In 
the  majority  of  these  cases  there  may  be  small  residuous  purulent  patches 

1  Moreau  has,  for  example,  a  quite  incomprehensible  and  vague  title,  "  Irrita- 
tion excessive,"  with  a  large  number  to  it. 

^  The  same  author  brings  forward  iodicy  with  an  enormous  number,  as  one  of 
the  physical  causes  of  mental  disease. 

^  See,  further  on,  the  special  description  of  epilepsy  as  a  complication. 


124:  THE    CAUSES    OF    INSANITY. 

wliicli  long  remain  withoiit  any  injurious  consequence,  or  small  apo- 
plectic cysts,  chronic  processes  in  tlie  dura  mater,  etc.,  around  which 
there  arises,  later,  without  any  cause,  a  gradually  extending  inflamma- 
tion of  the  delicate  membranes  or  of  the  cerebral  substance.  In  other 
cases  there  is  slowly  formed  an  exostosis,  a  tumor,  or  chronic  caries  of 
the  skull,  from  which  hyperremias  and  exudative  processes  proceed. 
Occasionally,  however,  nothing  of  this  sort  can  be  perceived;  it  appears 
that  in  certain  cases  concussion  may,  without  there  being  any  anatomical 
lesion,  be  followed  by  such  results  within  tlie  brain  that  it  remains  for 
years  after  very  suscejotible  to  disease,  so  that  after  the  slightest  exciting 
cause  (for  example,  a  moral  cause)  insanity  is  produced. 

It  frequently  happens  that  on  minute  inquiry  the  physician  learns  from  the 
relatives  of  tiie  patient  of  former  circumstances  of  this  kind  which  had  been 
almost  forgotten — a  severe  kick  from  a  horse,  a  fall  or  blow  on  the  head  which 
was  followed  by  insensibility.'  Sometimes  the  friend  now  remembers  for  the 
first  time,  that  since  the  accident  a  certain  change  has  taken  place  in  the  character 
of  the  patient — that  he  had  become  fretful,  irritable,  perverse,  etc.  This  cliange, 
however,  has  been  little  heeded,  and  had  not  even  been  recognized  in  its  true 
significance — as  a  precursor  of  insanity — when  the  disease -broke  out. 

We  quote  the  following  from  the  interesting  work  of  Schlager,  "  On  the 
Mental  Disorders  which  result  from  Concussii^n  of  the  Brain"  ('Zeitschrift  der 
k.  k.  Gesells.  der  Aerzte  zu  Wien,'  xiii.,  1857,  p.  454): — Amongst  500  patients  the 
author  discovered  49  (43  males  and  7  females)  in  wliom  the  development  of  the 
mental  disorder  stood  in  direct  relation  to  the  consequences  of  previous  concussion 
of  the  brain.  In  21  cases,  the  injury  was  followed  immediately  by  loss  of  con- 
sciousness; in  16,  by  simple  mental  confusion,  wandering  of  the  thoughts;  in  12, 
by  dull  pain  in  the  head.  In  19  cases  the  mental  disease  commenced  within  the 
first  year  after  the  accident,  but  in  the  great  majority  not  until  the  lapse  of  a 
much  longer  time;  in  4,  after  upwards  of  ten  years.  Generally,  the  individuals 
manifested  from  the  time  of  the  injnry  a  tendency  to  cerebral  congestion  after 
the  use  of  even  a  small  amount  of  spirits,  after  mental  excitement;  also  in  several 
cases  ocular  hyper^sthesiee  (subjective  impressions  of  light  and  of  color,  photo- 
phobia), often  amblyopia.  In  15  cases,  there  appeared  shortly  before  and  during 
the  existence  of  the  cerebral  disorder  black  specks,  which  exercised  a  deciding 
influence  on  the  character  of  the  delirium.  Very  often  also  the  patients  experi- 
enced ringing  and  noises  in  the  ears:  in  18  cases  there  was  dulness  of  hearing;  in 
3,  abnormal  subjective  perceptions  of  smell,  changes  in  the  pupils.  Very  often 
the  character  and  disposition  changed:  in  20  cases  great  irascibility,  an  angry 
passionate  manner  even  to  the  most  violent  outbursts  of  temper  was  remarked — 
less  frequently  over-estimation  of  self,  prodigality,  restlessness,  disquietude;  in 
14  cases  there  were  attempts  at  suicide,  frequently  weakness  of  memory,  confu- 
sion. The  prognosis  was  almost  always  unfavorable.  Seven  of  the  cases  ended 
in  general  paralysis,  10  cases  came  to  post-moilem  examination.  In  these  there 
were  found  occasionally  osseous  cicatrices,  adherent  dura  mater,  opacity  and 
serous  infiltration  of  the  delicate  membranes,  more  or  less  hydrocephalus  chroni- 
cus,  granulations  on  the  lining  membrane  of  the  ventricles;  in  one  case  a  cerebral 
induration,  witli  atrophy  of  the  brain  and  clironic  inflammation  of  the  delicate 
membranes.  Injury  of  the  cranial  bones  renders  the  probability  of  consequent 
psychical  disturbance  much  greater  than  simple  injury  of  the  soft  parts.  Very 
interesting  examples  of  insanity  consequent  upon  injuries  to  the  head  may  be 
found  in  the  '  Report  of  the  Vienna  Asylum  '  (1858,  p.  47). 

To  those  cases  which  result  from  diseases  of  the  bones  in  consequence  of 

injury  may  be  added  insanity  from  caries  of  the  skull  owing  to  internal  causes, 

especially  from  caries  of  the  temporal  bone,  internal  otitis  with  its  results, 

thrombosis,  meningitis,  etc.     Jacobi'^  has  observed  7  cases  of  the  latter  kind;  they 

.  never  admit  of  recovery,  and  but  seldom  of  improvement.     In  the  asylum  at 

'  In  a  similar  manner,  we  frequently  see  also  severe  spinal  neuroses  appear  for 
the  first  time  long  after  the  accident.  Jakubowsky  ('  Chorea  St.  Viti  traumaticae 
exemplum,'  Krakau,  1838,  Gratulationschrift)  relates  a  case  of  St.  Vitus'  dance 
of  this  kind  which  appeared  several  months  after  the  receipt  of  a  kick  on  the  back 
from  a  horse;  subsequent  recovery. 

"  '  Die  Hauptformen,'  etc.,  p.  663. 


THE    CAUSES    OF    IK8ANITY.  125 

New  York,  7  cases  occurred  in  a  single  year  in  which  mental  disease  originated 
from  diseases  of  the  internal  ear  fHanbury  Smith,  '  Annal.  Med.  Psychol.,'  1854, 
vi.,  p.  450).  Cases  have  been  observed  in  which  a  violent  attack  of  mania  ensued 
on  cessation  of  a  purulent  discharge  from  the  ear,  and  ceased,  or  at  least  con- 
siderably diminished,  on  the  return  of  the  discharge  (L.  Meyer,  '  Deutsche  Klinik,' 
1855,  No.  6). 

Along  "with  injuries  to  the  head  we  may  also  mention  insolation  as  a  cause, 
though  not  of  frequent  occurrence,  of  insanity.  This  acts,  perhaps,  by  causing 
great  cerebral  hyperemia  (and  oedema?);  perhaps  the  insanity  is  due  to  exces- 
sive nervous  irritation  of  the  brain  caused  by  pi'olonged  exposure  to  the  rays  of 
a  burning  sun.  Ellis'  mentions  two  cases  of  insanity  caused  by  insolation:  one 
of  them  ended  in  recovery,  the  other  in  dementia. 

Those  cases  in  which  insanity  originates  after  (and,  without  doubt,  in 
consequence  of)  a  relatively  insignificant  injury  of  a  jieri/pheral  nerve 
(above  all,  wounds  of  the  soft  tissues),  or  disease  of  a  nerve  of  sense 
commencing  at  the  periphery — for  example,  peripheral  deafness — are  of 
very  great  pathological  interest.  Thus  we  have  seen  an  attack  of  pro- 
found melancholia  occur  in  a  hysterical  woman  after  a  slight  injury  of 
the  eye  caused  by  a  splinter  of  wood;  insanity  has  also  been  observed 
(Herzog)  to  occur  after  the  operation  for  strabismus.^  Foville^  mentions 
numerous  cases  of  superficial  disease  of  the  cerebellum  in  the  insane  in 
consequence  of  peripheral  disorders  of  the  fifth  and  auditory  nerves;  to 
this  pathogenic  category  belongs  also  the  case  already  quoted  from  Jor- 
dens,""  of  a  boy  who  became  maniacal  through  a  small  piece  of  glass  pene- 
trating the  sole  of  his  foot,  and  continued  so  until  the  glass  was  removed. 
It  is  very  probable,  too,  that  the  cases  mentioned  by  Zeller,^  of  insanity 
consecutive  to  simi^le  external  wounds  of  the  head,  may  also  be  ranged 
under  this  head.''  Inasmuch  as  these  cases  vividly  remind  us  of  the 
delirium  nervosum  observed  after  and  sometimes  during  operations,  this 
cerebral  affection  may  be  compared  to  that  affection  of  the  spinal  cord 
which  determines  traumatic  tetanus;  but  with  this  difference — that  the 
spinal  cord  and  the  brain  always  react  according  to  their  own  peculiar 
energv. 

In  the  next  place,  we  may  here  mention  various  other  powerful  or 
long-continued  nervous  irritations  from  the  periphery  of  the  organism. 
As  an  example  of  the  first  series,  we  may  mention  that  remarkable  case 
recorded  by  Esquirol,  of  mania  occurring  after  a  strong  impression  of 
smell;  of  the  second  series,  perhaps,  e.  g.,  the  irritation  ])rodaced  Avithin 
the  bowels  by  ta?nia  and  other  entozoa,  or  even  of  pruritus  chronicus. 
Very  severe  pain  may  also  call  forth  an  attack  of  insanity  in  an  individ- 
ual who  is  predisposed.  The  'Report  of  the  Vienna  Asylum'  (1858,  \). 
60)  contains  a  case  of  this  kind,  in  consequence  of  severe  pain  resulting 
from  inflammation  of  one  of  the  tendinous  sheaths  in  the  palm  of  the 
hand. 

§  104.  Formerly  existing  spinal  neuroses,  whether  manifested  in 
states  of  developed  hysteria,  or  merely  in  limited  convulsive  or  neuralgic 
affections,  may  become  important  causes  of  insanity.  Here  it  seems  that 
mental  disorders  may  originate  as  well  from  a  gradual  extension  over 
more  considerable  portions  of  the  nerve  centres — and  this  is  very  fre- 

'  •  Traite  de  I'Alienation,'  etc.,  par  Archambault,  1840,  p.  81. 
-  Oppenheim"s   '  Zeitschrift,'  xxi.,    1842,   p.    101.     From   the   'St.    Petersburg 
Transactions,'  where  I,  alas!  could  not  read  the  case  in  the  original. 
"  '  Note  an  die  Academie,  I'lnstitut,'  Jan.,  1843. 
^  '  Hufeland's  Journal,'  vol.  iv.,  p.  244. 
^  '  Zeitschrift  fiir  Psychiatrie,'  i.,  1,  p.  49. 
''  See  moreover  the  case  mentioned  by  Hirsch  ('  Spinaineurosen,'  p.  131). 


126  THE    CAUSES    OF   INSANITY. 

quently  the  case  with  hysterical  persons — as  from  a  rapid  transition  from 
one  part  of  the  nervous  system  to  another:  in  the  latter  case  the  insanity 
may  frequently,  and  even  periodically,  alternate  with  other  nervous 
affections.  Thus  Brodie'  narrates  the  case  of  a  lady  who  for  a  year  suf- 
fered from  permanent  convulsion  of  the  sterno-mastoid  muscle;  suddenly 
tlie  convulsive  state  ceased,  and  she  fell  into  melancholia.  The  melan- 
cholia lasted  for  a  year,  when  her  mental  health  returned ;  but  the  muscu- 
lar convulsion  returned  also,  and  continued  for  several  years.  In  another 
case,  also  reported  by  Brodie,  a  neuralgic  state  of  the  vertebral  column 
alternated  with  true  insanity. 

Concei'ning  Hysteria  proper.  This  general  affection  of  the  nervous 
system  is  manifested  sometimes  more  in  one,  sometimes  more  in  another 
part  of  the  nervous  apparatus:  only  very  seldom,  however,  do  the  mental 
faculties  remain  entirely  free  from  all  disturbance.  In  the  ordinary 
slight  cases  which  cannot  as  yet  be  considered  as  mental  diseases,  Ave  see, 
sometimes  together  with  marked  motory-sensitive  anomalies,  sometimes 
without  them,  as  a  predominating  affection,  the  peculiar  hysterical  dis- 
position, viz.,  immoderate  sensitiveness,  especially  to  the  slightest  re- 
proach— tendency  to  refer  everything  to  themselves;  great  irritability, 
great  change  of  disposition  on  the  least  or  even  from  no  external  motive 
(humors,  caprices),  and  not  the  slightest  reason  can  be  given  for  the 
change  they  often  exhibit  tender  sympathy  for  other  female  individuals, 
peculiar  eccentricities,  very  lively  intellects  (in  young  girls,  pleasure  in 
learning,  etc.).  This  general  state  comprises  many  peculiarities  of  char- 
acter, often  of  quite  another  kind,  as  tendency  to  deception  and  prevari- 
cation, to  all  kinds  of  misdemeanors.  Jealousy,  malice,  etc. 

Serious  hysterical  mental  disorders  are  manifested  principally  in  two 
different  forms.  In  the  first  place  as  acute  attacks  of  delirium  and  ex- 
citement even  to  developed  mania.  These  are  developed  sometimes  from 
ordinary  hysterical  convulsive  attacks,  which,  however,  may  be  very 
slight;  sometimes  they  appear  to  occur  instead  of  these  convulsive  attacks, 
which  are  then  entirely  absent  (as  occurs  in  epilepsy).  Such  maniacal 
attacks  are  sometimes  observed  in  very  young  girls,  and  manifest  them- 
selves by  vociferation,  singing,  cursing,  aimless  wandering;  occasionally 
by  more  formal  delirium,  attempts  at  suicide,  nymphomaniacal  excite- 
ment, occasionally  by  delirium  of  a  religious  or  demoniacal  character;  or 
there  are  attacks  of  all  kinds  of  noisy  and  perverse,  but  still  coherent, 
actions.  In  either  case  they  retain  but  slight  remembrance  of  what  took 
place  during  tlie  disorder.^ 

The  chronic  form  of  hysterical  insanity  may  show  itself  in  the  form 
of  melancholia  or  mania.  It  commences  sometimes  as  a  slow  gradual  in- 
crease of  the  habitual  hysterical  disposition;  the  symptoms  gradually 
appear  more  persistent  and  more  intense,  the  patient  becomes  more  and 
more  incapable  of  self-control;  sometimes  it  commences  acutely  under 
the  influence  of  mental  emotion  or  menstrual  derangement,  weakness 
owing  to  various  acute  diseases — after  a  few  slight,  perhaps  incomplete, 
hysterical  attacks.  At  first,  moderate,  but  easily  noticed,  changes  of 
character  are  observed;  greater  seriousness,  egotism,  great  care  of  the 
health  is  manifested — indecision  and  absence  of  will,  impatience,  violence, 
tendency  to  anger.    The  patients  always  grow  lean,  ansemic,  occasionally 

'  '  Lectures  on  certain  Local  Nervous  Affections,'  London,  1837,  p.  8. 
-See  L.  Meyer,  "Ueber  acute  todliche  Hysterie,"  Virchow's   '  Archiv,'  ix., 
1856,  p.  98. 


THE    CAUSES    OF    INSANITY.  127 

quite  marasmatic;  they  suffer  from  constipation,  from  disorders  of  diges- 
tion and  menstruation;  occasionally  the  more  serious  chronic  forms  of 
melancholia  and  mania  are  developed;  temporary  exacerbations  frequently 
occur  with  marked  cerebral  congestion,  swelling  of  the  upper  lip,  violent 
headache,  or  sym})toms  of  diarrhoea.  The  symptoms  almost  always 
become  aggravated  at  the  menstrual  period.  An  erotic  element  may  fre- 
quently be  recognized  in  the  disposition  and  delirium  of  these  patients; 
in  many  instances  it  is  very  slightly  marked,  and  not  unfrequently  it  is 
altogether  absent.  Ecstatic  states  are  occasionally  presented  in  the 
higher  grades;  hysterical  insanity  passes  more  frequently  into  dementia 
than  one  might  at  first  believe. 

The  diagnosis  of  hysterical  insanity  is  principally  based  upon  former 
peculiarities  of  character,  present  or  past  existence  of  globus  hystericus, 
meteorismus,  convulsive  attacks,  local  anaesthesias  and  hyperaesthesias, 
symptoms  of  paralysis.  Very  frequently  we  find  in  these  individuals  a 
well-marked  hereditary  disposition  to  nervous  diseases,  chlorotic  appear- 
ances, disorders  of  menstruation  (which,  however,  often  disappear  with- 
out any  improvement  of  the  hysteria),  and — of  the  greatest  importance 
in  regard  to  prognosis  and  treatment — local  diseases  of  the  genital 
organs.  Some  cases  may  doubtless  be  attributable  to  non-satisfaction  of 
the  sexual  aj^petite;  but  this  is,  as  a  rule,  much  overrated,  as  the  exist- 
ence of  hysteria  in  girls  who  have  not  reached  the  age  of  puberty,  its 
great  frequency  amongst  married  women — the  frequent  injurious  influ- 
ence of  marriage,  pregnancy,  and  childbirth,  and  the  frequency  of  the 
affection  amongst  prostitutes,  shows. 

Fully  developed  hysteria  occurs  also,  although  more  rarely,  in  young  men 
(besides  many  other  cases,  I  have  recently  observed  such  a  one  with  distinct 
globus  and  convulsions  in  a  young  married,  very  anaemic  man,  whose  wife  was 
pregnant).  I  do  not  know,  however,  whether  hysterical  insanity  has  ever  been 
observed  in  men. 

§  105.  2.  Acute  fehrile  diseases  of  different  kinds  occasionally  give 
rise  to  an  outbreak  of  insanity;  the  disorders  which  they  occasion  within 
the  organism  seem  to  be  the  only  causes  of  the  insanity.  Typhus  fever, 
intermittent  fever,  cholera,  the  acute  exanthemata,  pneumonia,  and  acute 
rheumatism,  are  the  diseases  in  which  it  occurs  most  frequently.  In  re- 
gard to  the  latter,  the  facts  are  as  yet  little  known  and  studied:  we  shall 
here  give  this  remarkable  cause  of  mental  disorders  the  consideration 
which  it  deserves. 

After  tyi^hus  fever,  and  as  well  after  a  slight  as  after  a  severe  at- 
tack, it  is  not  at  all  rare  to  see  a  slight  degree  of  mental  disorder  which 
may  be  placed  in  the  same  category  with  the  slight  affections  of  other 
parts  of  the  nervous  system — incomplete  ansesthesias,  transient  paralyses 
of  the  extremities,  etc.  The  patient,  now  quite  free  from  fever,  or  even 
become  convalescent,  retains  either  some  fragments  of  his  former  delirium, 
or  he  exhibits,  independently  of  this,  all  kinds  of  perversities — erroneous 
ideas  on  various  subjects,  sometimes  even  in  regard  to  himself;  also  hallu- 
cinations, with  nervous  exhaustion  and  weakness,  without  profound  ex- 
citation of  sentiment.  This  form  of  mental  disturbance,  this  species  of 
fragmentary  delirium,  admits  of  an  altogether  favorable  prognosis,  and 
almost  always  disappears  rapidly  when  the  nutrition  is  improved  and  the 
strength  increased,  even  though,  as  sometimes  occurs,  a  certain  degree 
of  maniacal  excitement  be  associated  with  it.  But  there  are  also  much 
more  severe  cases  of  true  chronic  insanity  which  commence  during  con- 
valescence from  typhus  fever,  or  can  at  least  be  traced  to  this  and  to  its 


128  THE    CAUSES    OF    INSANITY. 

slow  commencement.  Melancholia,  wliicli  gradually  increases;  occasion- 
ally it  is  accompanied  with  stupor — sometimes  with  ideas  of  poisoning, 
refusal  of  food,  early  intermixture  of  symptoms  of  mental  weakness,  and 
transition  to  mania  and  profound  dementia; — such  is  the  ordinary  course 
of  these  cases  in  which  recovery  of  the  cerebral  functions  does  not  take 
place,  which  perhaps  depend  on  permanent  disturbances  of  nutrition  of 
the  brain;  but,  at  all  events,  the  prognosis  is,  according  to  experience, 
always  unfavorable. 

Those  who  have  written  upon  typhus  fever— for  example,  Chomel,  Louis  (ii., 
p  33,  2d  ed.),  Simon  ('  Journal  des  Connais.  Med.-Chir..'  Aoiit.  1844,  p.  53),  Sau- 
vet  (' Annal.  Med.  Psychol.,'  1845,  vi.,  p.  223),  Leudet  (ibid.,  1850,  p.  148),  Thore 
(ibid.,  p.  596).  Sclilager  ('Oesterr.  Zeitschrift  fiir  prakt.  Heilk.,'  1857,  33-35). 
Tiingel  ('  Clinische  Mittheilungen,'  Hamburg,  1860,  p.  18)— have  communicated 
cases  of  this  description.  Jacobi,  in  one-eighth  of  his  cases  of  mania,  ascribes 
the  disease  to  the  consequences  of  typhus  fever:  it  appears  to  me  very  doubtful, 
however,  whether  this  has  always  been  true  typhus.  Schlager  found  amongst 
500  mentally  diseased,  22  cases  \vhich  could  be  traced  to  typhus  fever.  I  cannot 
indorse  the  opinion  that  the  foundation  of  these  cases  is  to  be  sought  in  the 
hypertemia  of  the  brain  which  remains  after  typhus  fever;  all  point  rather  to 
states  of  aneemia  and  exhaustion,  occasionally  even  with  remnants  of  the  fever. 
In  exceptional  cases,  these  diseases  may  be  caused  by  the  presence  of  sanguine- 
ous clots  in  the  sinus  of  the  dura  mater,  perhaps  by  meningitis  or  by  acute  atrophy 
of  the  brain. 

The  relation  of  certain  cases  of  mental  disease  to  intermittent  fever 
has  been  observed  since  tlie  days  of  Sydenham.  Here,  too,  a  very  differ- 
ent relation  of  the  two  affections  to  each  other  is  to  be  distinguished.  In 
the  one,  perhaps  the  smallest,  series  of  cases,  we  see  that  in  localities 
where  intermittent  fever  is  endemic,  certain  individuals  are  attacked, 
instead  of  ordinary  ague,  by  an  intermittent  cerebral  affection  which 
manifests  itself  in  regular  (tertian,  quartan)  attacks  of  insanity  (so-called 
intermittens  larvata).  There  are  here  generally  certain  signs  of  the  stages 
of  the  attack — yawning,  rigors,  heat — to  be  observed,  and  it  is  the  hot 
stage  especially  Vhich  is  most  frequently  complicated  with  cerebral  con- 
gestion to  such  an  extent  as  to  produce  mania.  It  is,  therefore,  not  an 
existing  intermittent  fever,  but  the  endemic  cause  of  the  fever,  which  is 
the  cause  of  the  insanity.  The  periodic  nature  of  the  attacks,  and  espe- 
cially great  increase  of  temperature  during  the  attack,  together  with  the 
endemic  character  of  the  fever,  are  the  principal  diagnostic  signs. 

Example  I.— A  young  man  had  five  attacks  of  mental  disorder,  one  every 
other  day.  The  attack  commenced,  after  very  slight  rigors,  with  an  indescribable 
feeling  of  pain  in  the  cardiac  region,  and  palpitation,  which  rapidly  increased  to 
a  state  of  extreme  anxiety.  This  formed  the  commencement  of  the  delirium, 
out  of  which  the  patient  emerged  bathed  in  perspiration,  after  a  deep  sleep.  He 
soon  recovered  under  the  treatment  for  intermittent  fever.     (Flemming,  '  Psy- 

chosen,'  p.  87.)  ,  .  „ 

Example  II. — A  strong  laborer,  set.  30,  who  had  never  had  mtermittent  fever, 
but  wiio  lived  in  one  of  the  many  fever  districts  which  surround  Siegburg,  was 
suddenly  seized  with  mania:  he  considered  himself  to  be  Christ  and  those  around 
him  to  be  witches;  he  abused  his  master,  etc.  The  head  was  hot;  the  eyes  red 
and  rolling  wildly;  the  tongue  Avhite;  epigastrium  distended;  the  pulse  somewhat 
rapid,  not  feverish;  the  feet  cold.  On  the  application  of  ice  to  the  shaven  scalp, 
etc.,  the  patient  became  calm,  and  during  the  two  following  days  seemed  to  be 
mentally  healthy.  On  the  fourth  day,  exactly  at  the  same  hour,  the  same  scene 
was  repeated  (sal  ammoniac,  extr.  trifol.,  and  tartar  emetic).  A  third  attack 
occurred  in  the  quartan  type,  but  milder,  shorter  in  duration,  and  succeeded  by 
sweating:  after  this,  the 'symptoms  disappeared  under  the  use  of  quinine.  In 
spite  of  the  continued  vise  "of  quinine,  there  occurred  after  five  weeks  a  fourth 
attack  of  this  periodic  insanity,  which  however,  like  a  subsequent  one,  whicli  was 
the  last,  finally  gave  way  under  felie  administration  of  bark  and  quinine.  (Focke, 
'  Zeitschrift  fiir  Psychiatric,'  v.,  p.  376.) 


THE    CAUSES    OF    INSANITY.  129 

At  other  times,  after  an  ordinary  intermittent  fever  has  lasted  for  a 
certain  time,  there  appear,  instead  of  the  paroxysms  of  heat  and  cold — as 
if  through  a  leap  of  the  affection — intermitting  paroxysms  of  insanity 
(violent  attacks  of  mania  with  delirium,  also  impulsive  suicide  during  the 
fit) :  these  states  often,  with  disappearance  of  decided  periodicity,  assume 
the  remittent  and  continuous  type,  and  pass  into  chronic  mental  diseases. 
Finally,  there  is  a  third  mode  of  origin  which  is  the  most  frequent  of  all: 
the  insanity  occurs  as  a  disease  consequent  upon  intermittent  fever  which 
has  disappeared  either  in  the  early  stage  of  convalescence,  or  not  until 
several  months  after  the  cessation  of  the  ague.  It  is  especially  after  very 
protracted  and  severe  (especially  quartan)  fevers  that  disorders  remain 
which  may  produce  insanity. 

The  mental  disease  frequently  continues  as  a  uniform  persistent 
chronic  affection,  and  the  symptoms  of  the  intermittent  fever  are  no 
longer  observed.  Or  traces  of  the  fever  may  still  be  present;  the  spleen 
and  liver  are  enlarged,  cachexias  exist,  and  irregular  paroxysms  of  ague 
appear  from  time  to  time  (during  the  mental  disease).  In  cases  of  the 
latter  kind  especially,  the  insanity  frequently  ceases,  sooner  or  later,  with 
the  return  of  an  acute  series  of  a  severe  attacks  of  intermittent  fever,  but 
by  the  use  of  quinine  the  collective  intermittent  disease  may  be  removed. 
In  the  origin  of  all  cases  belonging  to  the  third  category,  it  is  certain 
that,  on  the  one  hand,  the  cachectic-ansemic  state  which  the  intermittent 
fever  leaves  behind  it,  and,  on  the  other,  the  melangemia  and  the  deposit 
of  granular  pigment  in  the  cerebral  vessels  must  play  an  important  part 
(on  this  subject  see  my  paper  on  infectious  diseases,  Virchow's  '  Patho- 
logie,'  ii.)  as  the  later  can  also  very  probably  call  forth  severe  acute  cere- 
bral affections  (coma,  apoplectiform  attacks,  etc. )  which  are  sometimes 
observed  in  intermittent  fever  {occasional  cases  belonging  to  the  first  and 
second  category).  Still,  post-mortem  examinations  occur  in  which  no 
pigmentation  of  the  brain  can  be  discovered.  ^ 

Jacobi  has  reported  three  cases  in  which  attacks  of  ague  occurred  instead  of 
insanity  (chronic)  which  existed,  and  with  those  the  disease  ceased  (a  so-called 
critical  phase  of  intermittent  fever). 

Koster  obsei-\'ed  that  in  24  cases  of  insanity  in  Siegburg  who  took  intermit- 
tent fever,  7  recovered,  7  were  improved,  and  in  10  no  change  resulted:  amongst 
the  latter,  however,  there  were  many  chx-onic  and  incurable  cases.  Amongst  the 
former  there  were  also  several  in  whom  the  prognosis  had  been  considered 
unfavorable.  Gaye,  in  the  Schleswig  Asylum,  observed  in  three  years  56  cases 
of  intermittent  fever  in  insane  patients,  "  but  only  exceptionally  have  favorable 
results  occuiTed." 

See  Sebastian,  "  Bemerkungen  iiber  die  Melancholie  und  Manieals  Nachkrank- 
heiten  der  Wechselfieber,"  'Hufeland's  Journal,'  1823,  Ivi.,  p.  3;  Mongellaz, 
'Monographic  des  Irritations  Intermittentes,'  Paris,  1839,  i.,  p.  638;  Lippich, 
"  Beitrage  zur  Psychiatrie,"  '  OesteiT.  Jahrbiicher,'  Juni,  1842,  p.  282;  BaUlarger, 
"Sur  la  Folic  a  la  suite  des  fie^^•es  intermittentes,"  '  Annal.  Med.  Psjxhol.,'  1843, 
ii.,  p.  372;  Focke,  "  Ueber  typisches  Irresein,"  '  Zeitschr.  f.  Psych.'' v.,  1828,  -p. 
375;  Koster,  '  Diss.,'  Bonn,  1848;  '  Bericht  der  Wiener  Irrenanstalt  (Wien,  1858), 
p.  51. 

Acute  mental  disorders  occasionally  occur  also  after  cholera  (asiatica). 
Sometimes  it  is  transient  delirium,  absence  of  mind,  perverted  instincts; 
sometimes  paroxysms  of  mania,  generally  of  short  duration  (several  days 
to  several  weeks),  which  terminate  in  exhaustion  and  sleep;  occasionally, 
also,  melancholia  of  somewhat  longer  duration,  with  insane  ideas,  and, 

1  Hoffmann  ('Giinsberg  Zeitschr.,' iv.,  p.  365).     The  insanity  had  originated 
after  intermittent  fever.     The  autopsy  showed  atrophy  of  the  brain;  "cortical 
layer  pale,  paler  than  the  central  gray  masses." 
9 


130  THE    CAUSES    OF    INSANITY. 

more  or  less,  with  appearance  of  mental  weakness.  The  prognosis  is 
generally  favorable,  and  most  of  these  cases  do  not  find  their  way  into 
the  asylums;  sometimes  the  individuals,  already  weakened  by  the  pre- 
vious serious  disease,  die  during  an  attack  of  mania;  occasionally,  also, 
they  pass  into  the  incurable  forms. 

See  Fischer,  '  Prager  Vierteljahrschrift,' vol.  xxxii.,  1851,  p.  85;  Delasiauve, 
'  Annal.  Med.  Psychol.,'  1849,  Seme  Ser.,  vol.  i.;  Neumann.  '  Lehrb.  d.  Psychia- 
tric,' 1859,  p.  164. 

Those  cases  of  insanity  are  very  interesting  which  appear  during  the 
course  of  pneumonia  (generally  acute  mania).  In  these  cases  the  insan- 
ity is  rarely  developed  at  the  commencement  or  at  the  height  of  the 
disease,  but  more  frequently  at  the  time  when  the  fever  ceases,  or  even 
not  until  convalescence  sets  in :  these  cases  are  by  no  means  to  be  con- 
founded with  the  ordinary  delirium  which  so  frequently  accompanies  the 
more  severe  cases;  they  are  generally  of  short  duration,  but  tend  to  pass 
into  chronic  insanity,  so  that  such  patients  ought  at  once  to  be  placed  in 
an  asylum.  It  is  not  unfrequently  slight  and  limited  pneumonias  which 
are  followed  by  mental  disease;  hereditary  predisposition  or  previous 
habits  of  drunkenness  may  frequently  be  recognized  as  predisposing  cir- 
cumstances. The  mental  disturbance  sometimes  passes  off  so  rapidly 
that  the  existence  of  a  palpable  cerebral  disease  is  very  improbable  and  is 
most  likely  dependent  upon  acute  anaemia  of  the  brain.  In  other  rare 
cases,  the  mental  affection  lasts  for  a  longer  time;  it  approaches  dementia, 
and  is  associated  with  certain  paralytic  appearances  in  the  muscles.  It  is 
probable,  therefore,  that  there  may  be  in  these  cases  sanguineous  clots 
in  the  sinuses,  encephalitis  or  localized  meningitis  which  may  gradually 
disappear,  sometimes  completely,  sometimes  incompletely. 

Cases  of  mental  disease  consecutive  to  pneumonia  may  be  found  in  Jacobi 
(29th  example  of  mania).  Thore  ('  Annal.  Med.  Psychol.,'  Mai,  1844,  p.  389,  and 
ibid.,  1850,  ii.,  p.  586)  has  several  very  interesting  cases.  One  of  these  patients 
had  two  successive  attacks  of  pneumonia,  each  of  which  was  followed  by  mental 
disorder.  Another  case  is  mentioned  by  Snell,  of  mania  after  pneumonia  in  a 
child  of  nine  years  (•  Zeitschr.  f.  Psych.,'  xiii.,  1856,  p.  540).  Two  of  these  rare 
cases  came  imder  my  observation  in  the  clinique  at  Tubingen,  both  in  the  same 
winter,  and  another  recently  at  Zurich;  two  of  them  belonged  to  the  first,  the 
case  in  Tiibingen  to  the  second,  of  the  above-mentioned  categories. 

Example  III. — Pneumonia ;  transient  mental  disorder  on  the  cessation  of  the 
fever. — C.  G— ,  set.  21,  vigorous  and  robust,  was,  on  the  26th  of  February,  1859, 
suddenly  seized  with  a  severe  rigor,  bleeding  at  the  nose  and  giddiness.  He  was 
admitted  into  my  clinical  ward  on  February  28th.  On  examination,  there  was 
found  pneumonia  of  a  portion  of  the  right  lower  lobe,  and  severe  typhus- 
like  symptoms  with  prostration;  there  was  a  good  deal  of  quiet  delirium;  respi- 
ration 39-40;  pulse  100-104;  temperature  40.3 "-41.0°  C.  On  the  third  day  of  the 
disease,  herpes  labialis  appeared,  which  did  not  develop  properly.  On  the 
fourth,  the  temperature  sank  from  40.3°  in  the  morning  to  39.2°  in  the  even- 
ing, pulse  92;  the  patient  became  more  delirious  and  absent.  On  the  fifth  day, 
the  physical  signs  indicated  complete  retrogression  of  the  local  process;  the  tem- 
perature is  in  the  morning  38.1°,  and  in  the  evening  38.2°  C;  pulse  66-72,  some- 
times intermittent.  The  countenance  is  pale;  the  patient  is  quite  without  sense 
— knows  not  where  he  is,  does  not  recollect  the  simplest  events,  talks  constantly 
and  dehriously,  and  towards  night  becomes  very  restless  and  unnily  (morphia). 
After  passing  a  very  restless  night,  he  next  morning  had  a  long  and  quiet  sleep: 
the  face  was  pale,  slightly  convulsed;  respiration  slow,  irregular;  pulse  60-66; 
temperature  37°  C.  From  this  time  the  patient  continued  free  from  fever;  the 
delirium,  ringing  in  the  ears,  and  vertigo  continued  for  two  days  longer,  after 
which  they  disappeared;  the  pulse  still  presented  great  irregularity,  and  from  the 
eighth  to  the  tenth  day  of  the  disease  fell  to  56-48.  On  the  thirteenth  day, 
resolution  of  the  pneumonia  was  complete,  tl>e  mental  state  was  quite  normal. — 
This  case  is  not  to  be  considered  one  of  febrile  delirium;  the  mental  disorder  was 


THE    CAUSES    OF    INSANITY.  131* 

quite  a  different  affection  from  the  preliminary  delirium,  and  did  not  appear  till 
the  fever  began  to  cease,'  the  temperature  to  diminish,  and  pulse  to  become  slow 
and  intermittent  (the  only  medicine  used  was  nitre).  The  case  which  recently 
came  under  my  observation  in  Zurich  was  very  similar  to  this:  the  following  is, 
however,  very  different. 

Example  IV. — Pneumonia,  mania,  slight  hemiplegia,  consecutive  mental  weak- 
ness.— J.  H — ,  aet.  24,  a  laborer,  was  admitted  into  my  clinique  on  the  21st  of 
January,  1859.  The  father  of  the  patient  died  in  his  fifty-second  year  from  a 
chronic  chest  affection,  with  dropsy.  His  mother  was  alive  when  the  patient 
entered  the  hospital,  but  during  his  residence  there  she  committed  suicide.  I^ — 
had,  on  the  whole,  always  enjoyed  good  health;  five  or  six  years  ago  he  was  sud- 
denly seized  with  weakness  and  loss  of  consciousness,  together  with  stiffness  of 
the  limbs:  this,  however,  disappeared  in  an  hour.  He  had  not  been  intemperate. 
Three  years  ago  he  fell  from  a  tree,  but  after  lying  for  a  short  time  unconscious 
he  rapidly  recovered.  At  midday,  on  the  16th  January,  the  patient  was  suddenly 
seized  with  pneumonia;  he  was  bled.  Had  not  been  delirious  at  home,  but  on 
the  day  before  his  admission  he  showed  symptoms  of  derangement;  during  the 
night  of  the  20th-21st  he  spoke  in  a  more  lively  manner  than  usual,  and  on  the 
morning  of  the  21st,  while  being  conveyed  to  the  hospital,  he  commenced  to  be 
delirious;  he  screamed  in  the  vehicle,  and  his  excitement  increased  as  he 
approached  the  town.  On  his  entrance  into  the  clinique,  he  was  quite  void  of 
sense,  looked  perplexedly  about,  stretched  his  arms  rigidly  before  him;  his  hands 
clenched;  he  gave  no  answers,  or  if  he  did  they  were  quite  incoherent.  After  a 
few  hours  he  partially  recovered  his  senses,  and  could,  for  the  first  time,  be 
minutely  examined.  His  face  was  more  flushed  than  during  the  delirium;  pulse 
76,  full;  the  left  pupil  more  dilated  than  the  right,  and  the  left  side  of  the  face 
seemed  slightly  paralyzed.  A  physical  investigation  resulted  in  the  discovery  of 
pneumonia  of  moderate  extent  of  the  right  lower  lobe,  without  complete  dulness; 
other  organs  normal,  urine  free  from  albumen  or  bile,  temperature  38.4  (marked 
remission  of  the  fever  on  the  fifth  day  of  the  pneumonia).  On  the  following  day, 
the  temperature  had  increased  from  39.7  in  the  morning  to  40.7  in  the  evening; 
marked  crepitation  in  the  right  lung;  the  pneumonia  has  not  extended.  The 
pulse  was  in  the  morning  82,  in  the  evening  108;  respiration  36-44.  The  patient 
is  in  a  state  of  constant  violent  agitation,  continually  asks  for  something  or  other, 
is  irritable,  refuses  everything,  and  very  rarely  gives  a  correct  answer.  In  the 
evening  his  state  passed  into  complete  mania,  so  that  he  had  to  be  put  into  the 
strait- jacket  and  into  a  cell;  on  this  being  done,  he  showed  great  acuteness  of 
the  senses. 

On  the  morning  of  the  23d,  the  temperature  had  again  fallen  to  38,  and  in 
the  evening  to  37.8;  the  percussion  note  was  somewhat  clearer;  the  crepitation 
diminished;  pulse  80-100.  The  patient  was  still  delirious,  but  not  so  restless; 
frequently  gave  correct  answers,  slept  occasionally  and  appeared  very  tired. 
But  on  the  following  day,  while  the  pneumonia  had  completely  disappeared,  the 
patient  exhibited  total  confusion  and  absence  of  mind;  during  nearly  the  whole 
of  the  night  he  ran  about,  drawing  off  and  on  his  shirt;  gives  no  answers,  or  if 
he  does  they  are  quite  incoherent.  The  temperature  could  not,  in  these  circum- 
stances, be  taken.  The  pulse  was  slow,  68;  the  patient  appeared  pale  and  col- 
lapsed; the  left  pupil  still  more  dilated  than  the  right;  the  left  side  of  the  face 
slightly  paralyzed;  no  trace  of  paralysis  of  the  extremities  (the  most  probable 
supposition  would  be  encephalitic  inflammation  owing  to  thrombosis  of  the 
sinus).  On  the  morning  of  the  26th,  after  the  patient  had  spent  almost  the  whole 
night  standing,  great  oedema  of  the  lower  extremities  up  to  the  middle  of  the 
thigh  was  found  (thrombosis  of  the  crural  veins);  the  temperature  was  not  so  high; 
pulse  124;  the  cardiac  impulse  strong  and  full.  Tlae  patient  sees,  hears,  and 
feels;  but  he  seems  as  if  the  sensorial  impressions  were  not  elaborated;  he  con- 
stantly looks  around  him  with  an  astonished  impression,  and  is  quite  without 
intelligence  (Infusum  Sennae;  a  blister). 

During  the  next  eight  days,  the  temperature — with  moderate  variations — 
gradually  sank  to  the  normal  standard,  the  oedema  of  the  lower  extremities  dis- 
appeared, now  and  then  perspirations  occurred,  the  pulse  remained  between  64 
and  80.  The  local  symptoms  of  the  pneumonia  had  quite  disappeared.  The  men- 
tal disorder  continued,  but  varied  in  intensity.     Sometimes  the  patient  was  so 

'  Metzger  (Henle  und  Pfeufer,  '  Zeitschrift,'  1858,  iv.,  p.  220)  has  also  commu- 
nicated four  instances  of  transient  mania  in  pneumonia,  which,  Jiowever,  appear 
to  have  commenced  at  the  height  of  the  disease  and  of  the  fever,  and  therefore 
have  quite  a  different  signification. 


132  THE    CAUSES    OF    INSANITY. 

Stupid  and  confused,  that  he  seemed  to  have  entirely  lost  his  senses;  sometimes 
he  seemed  to  understand  better  what  was  said  to  him,  and  to  express  himself  a 
little  more  connectedly;  sometimes  he  was  more  excited,  would  escape,  etc. 
Now  and  then  he  had  hallucinations — saw  figures,  heard  firing,  etc.  His  appear- 
ance was  that  of  one  who  had  a  serious  cerebral  disease  :  the  eye  was  fixed  and 
injected;  the  left  eyeball  was  somewhat  more  prominent  than  the  right,  and 
turned  slightly  inwards;  the  mydriasis  was  much  diminished;  the  tongue  for 
several  days  inclined  a  little  to  the  right.  Gradually  the  patient  commenced  to 
walk  about;  but  he  always  staggered,  and,  without  any  symptoms  of  paralysis  of 
the  extremities,  it  was  remarked  that  he  allowed  the  whole  of  the  left  side  to 
hang  somewhat.  The  patient  remained  in  the  clinique  until  the  10th  May,  1859. 
He  was  at  this  time  entirely  without  feverishness.  His  mental  state  was  at  first 
that  of  profound,  and  afterwards  that  of  declining  dementia.  At  first  he  was 
quite  stupid,  quite  incapable  of  deliberation;  he  spoke  none  at  all,  or  as  if  he  were 
in  a  dream,  and  generally  about  nothing  but  eating;  at  the  same  time  he  appeared 
to  be  in  great  anxiety.  By  slow  degrees  his  mental  state  commenced  to  improve; 
he  became  cleanly  in  his  habits;  on  some  days  he  gave  correct  and  on  others  very 
incorrect  answers.  His  behavior  continued  to  be  very  childish,  yet  it  gradually 
became  more  cheerful.  The  symptoms  of  weakness  of  the  left  side  improved 
quite  as  slowly  and  incompletely  as  those  of  the  mental  disorder;  even  at  the 
date  of  the  patient's  dismissal,  the  left  pupil  was  slightly  dilated,  the  tongue 
inclined  slightly  towards  the  left  side,  and  when  walking  the  left  side  of  the  body 
■was  still  a  little  dependent.  He  often  complained  of  tiredness  and  of  frontal 
headache;  occasionally  also  epistaxis  occurred.  It  was  a  very  remarkable  cir- 
cumstance that,  on  the  cessation  of  the  fever,  polyuria  set  in  and  continued  for 
several  weeks;  the  pale  urine,  the  quantity  of  which  sometimes  amounted  to 
4000  C.C.M.  in  the  twenty-four  hours,  had  a  specific  gravity  of  1006  to  1008. 
The  ordinary  sugar-test  afforded  a  negative  result.  A  minute  examination  in 
the  chemical  laboratory  showed  that  it  also  contained  no  phosphates.  The 
patient  sometimes  complained  of  slight  pains  in  the  region  of  the  kidneys.  This 
diuresis  disappeared  during  the  last  week  of  his  residence  in  the  hospital,  when 
also  the  nutrition  became  quite  normal,  and  the  patient  quite  well.  On  his  dis- 
missal on  the  10th  May,  he  understood  all  that  was  said  to  him,  and  could  express 
himself  quite  correctly,  though  with  a  little  hesitation,  on  most  subjects.  He 
called  about  f ovuteen  days  afterwards,  and  there  was  no  alteration  in  his  mental 
state. 

Acute    rheumatism,   like  pneumonia,    causes   the    development   of 
mental  disease  but  very  rarely,  and  we  shall  have  to  conceive  of  the  rela- 
tion which  exists  between  the  insanity  and  the  acute  disease  as  somewhat 
different  from  that  just  spoken  of.     It  appears,   namely,  that  these 
mental  disorders  ought  not  to  be  considered  as  sequelce  or  accidents  of 
convalescence,  but  that  they  are  only  a  protracted  form  of  that  cerebral 
affection  appearing  in  various  forms,  and  in  its  acute  development  often 
so  very  dangerous,  which  frequently  appears  in  acute  rheumatism,  either 
simple,  or  complicated  with  cardiac  inflammations,  which  leaves  behind 
it  no  definite  anatomical  changes,  and  therefore  is  most  conveniently 
designated  rheumatic  cerebral  disorder.     The  acute  cerebral  symptoms 
consist  here  sometimes  in  acute  delirium  and  maniacal  excitement,  which 
may  terminate  in  death  or  soon  disappear  (in  other,  still  more  serious 
cases,  the  symptoms  are  chiefly  those  of  coma).     Sometimes — and  these 
are  the  cases  which  now  occupy  us — under  the  influence  of  accessory 
causes,  we  see  prolonged  melancholia  with  stupor,  mania,  mental  weakness, 
etc.,  occur — in  short,  the  development  of  actual  mental  disease  in  various 
protracted  forms,  sometimes  associated  with  cliorea-like  attacks.    In  these 
as  in  the  acute  cerebral  forms  of  rheumatism,  we  frequently  see  the 
articular  affection  diminish  or  even  disappear  with  the  appearance  of  the 
mental  disturbance,  and  occasionally  there  is  an  alternate  improvement 
of  the  one  and  aggravation  of  the  other,  sometimes  even  a  decided 
retrogression  of  the  latter  on  the  reappearance  of  the  former. ' 

*  See  the  author's  paper  "  On  the  Protracted  Form  of  the  Rheumatic  Cerebral 
Disorder;"  '  Archiv  der  Heilkuude,'  i.,  3,  1860,  p.  235. 


THE    CAUSES    OF    INSANITY.  133 

Example  V. — Commencement  of  insanity  during  acute  rheumatism,  with 
disappearance  of  the  articular  affection;  mental  improvement  icith  return  of  the 
disease  in  the  joints;  fluctuating  state;  recovery  in  about  three  months. — E.  D — , 
set.  50,  a  very  poor  unmarried  woman,  was  on  the  10th  of  March,  1857,  admitted 
into  the  clinique  at  Tiibiugen.  The  following  was  learned  concerning  her: — 
Twenty  years  ago,  after  her  second  confinement  she  became  insane;  she,  how- 
ever, recovered  after  three  months,  and  since  then  she  has  given  birth  to  another 
child  without  any  consequent  disorder.  For  the  last  ten  years  she  had  been  in 
the  continuous  enjoyment  of  good  health.  About  four  or  five  weeks  ago  she 
suddenly  became  ill:  at  first  she  complained  much  of  toothache;  she  became 
feverish,  and  many  of  the  joints  of  the  upper  and  lower  extremities  became 
swollen  and  painful — acute  rheumatism  had  set  in.  About  ten  days  after  its 
first  appearance  the  articular  afl'ection  disappeared  rather  suddenly,  and  at  the 
same  time  the  patient  became  mentally  deranged.  She  was  delirious,  understood 
nothing,  attacked  those  about  her;  was  sometimes  very  quiet,  at  others  very 
loquacious;  ran  about  crying  all  night;  searched  out  all  her  effects,  and  threw 
them  about;  in  short,  she  behaved  in  all  respects  like  an  insane  person.  She 
slept  and  ate  very  little,  drank  a  great  deal,  and  occasionally  i-eplied  in  answer  to 
questions  put  to  her  that  every  part  of  her  body  was  jDainful. 

On  admission,  the  patient,  who  was  very  strong  for  her  age,  appeared  pale: 
she  was  perfectly  free  from  fever;  had  no  cardiac  affection,  nor  pain  in  any  of 
the  joints.  She  was  in  a  state  of  well-marked  melancholia  with  stupor  (melan- 
cholia attonita);  her  look  was  shy  and  anxious;  she  was  quite  concentrated  in 
herself,  and  evidently  in  a  state  of  prolonged  dreaming;  she  spoke  very  little, 
and  quite  confusedly.  She  continued  in  this  state  for  two  days  after  her  admis- 
sion. On  the  second  day  (12th  March)  she  became  more  restless,  and  spoke  con- 
tmuously  during  the  whole  of  the  night.  In  the  morning  she  spoke  generally  in 
rhyme :  for  example,  ' '  God  knows  what  I  try  for,  He  sees  what  I  cry  for,  and 
He  hears  my  prayer — shall  I  see  Him  there?"  etc.  During  the  visit,  she  broke 
into  an  outburst  of  anger,  accused  those  present  of  having  taken  her  children; 
she  had  to  be  confined  in  a  refractory  cell. 

On  the  14th  March,  oedema  of  the  lower  extremities  set  in;  the  patient  was 
free  from  fever;  the  pulse  calm;  bowels  constipated;  urine  free  from  albumen. 
During  the  day  she  was  much  quieter,  she  had  numerous  hallucinations  of  a 
gloomy  character;  during  the  night  she  again  became  excited.  During  the  fol- 
lowing days  the  oedema  of  the  feet  increased,  and  appeared  also  in  the  hands;  on 
the  19th  there  appeared,  together  with  the  oedema,  redness  and  swelling  of  the 
finger-joints,  which  were  very  sensitive  to  pressure  (only  shown  by  gestures); 
the  right  ankle-joint  was  also  very  painful  on  pressure.  Percussion  and  auscul- 
tation of  the  heart  and  organs  of  respiration  showed  not  the  slightest  change; 
pulse  84,  full;  skin  dry  and  warm;  appetite  moderate;  bowels  regular.  The 
patient  lay  in  bed,  was  quiet;  on  being  questioned,  she  generally  made  no  reply 
— at  most  occasionally,  and  slowly,  yes  or  no;  the  physiognomical  expression 
was  that  of  indifference  and  apathy;  now  and  then  she  searched  the  wall  around 
her  bed,  and  seems  quite  in  a  dream  (Nitre  3  ij.).  On  the  following  day  the  pain 
and  swelling  of  the  joints  had  again  almost  disappeared;  she  again  became  much 
more  restless,  very  talkative,  said  that  her  children  were  outside  and  ought  to  be 
beheaded,  etc.  From  this  date,  20th  March,  the  patient  continued  in  a  state 
which  it  would  be  needless  to  describe  day  by  day.  The  rheumatic  articular 
affection  never  attained  to  any  great  intensity,  but  there  was  frequently  a 
moderate  degree  of  swelling  and  of  pain  in  certain  joints  of  the  fingers  and  feet; 
she  often  complained  of  pain  in  the  limbs  and  joints,  and  of  stiffness  of  the  whole 
body.  She  was  consequently  almost  always  confined  to  bed,  but  free  from  fever; 
there  was  never  any  cardiac  disorder;  the  urine  continued  non-albuminous; 
appetite  and  sleep  slowly  returned  (Colchicum  and  Opium).  Therewith  the 
patient,  with  numerous  interruptions  of  restlessness,  confusion,  and  loquacity, 
became  gradually  more  calm  and  more  reasonable,  to  manifest  a  more  lively  dis- 
position, and  by-and-by  commenced  to  do  a  little  work.  She  had  not  the  slightest 
recollection  of  the  first  period  of  her  residence  in  the  hospital.  By  the  middle  of 
April  the  patient  could  be  considered  as  quite  recovered  in  mind;  for  some  time 
after,  however,  she  complained  of  frequent  startings,  giddiness,  and  ringing  in 
the  eai"s;  and  traces  of  pain  and  swelling  remained  in  some  of  the  joints  until  the 
beginning  of  May.  These  were  dispelled  by  the  judicious  use  of  baths,  and  on 
the  12th  May  the  patient  was  dismissed  cured. 

Example  VI. — A  delicate  lady,  30  and  odd  years  of  age,  who  had  hitherto 
enjoyed  good  health,  was  somewhat  debilitated  by  her  last  confinement,  and  had 


134  THE    CAUSES    OF    INSANITY. 

a  tedious  recovery,  owing  to  an  attack  of  articular  rheumatism.  Modified  hydro- 
pathic treatment  was  employed — cold  fomentation  of  the  affected  parts.  The 
pain  and  sweUing  rapidly  disappeared,  and  the  limbs  became  free  and  movable. 
But  immediately  she  began  to  complain  of  drawing  pains  along  the  spine,  rest- 
lessness and  stretching,  straining,  occasionally  jerking  movements  in  the  extremi- 
ties. At  the  same  time  there  appeared  in  a  few  days  a  state  of  mental  depression, 
which  rapidly  increased,  and  assumed  the  form  of  apathy,  and  finally  of  com- 
plete insensibility.  The  patient  was  now  confined  to  bed;  felt  disinclined  to 
move,  to  dress  herself,  and  even  to  eat;  she  was  mute  and  indifferent  to  all  but 
very  strong  impressions;  in  a  short  time  she  presented  the  characteristic  appear- 
ance of  melancholia  attonita.  The  whole  expression  seemed  less  to  betray  men- 
tal pain  than  complete  indifference  (even  to  ordinary  personal  cleanliness), 
together  with  an  aversion  to  all  kinds  of  excitement,  which  was  manifested  by 
strong  expressions  of  displeasure  (throwing,  striking,  etc.).  The  disease  termi- 
nated favorably;  the  patient  recovered  under  the  influence  of  baths  containing 
malt  and  salt,  an  issue  in  the  neck,  flying  blisters  applied  to  the  spine,  aconite 
with  guaiacum,  and  afterwards  see-bathing. — (Flemming,  '  Psychosen,'  p.  88.) 

Mental  disease  has  also  been  observed,  though  very  rarely,  to  origi- 
nate rapidly  after  small-pox,  measles,  and  erysipelas — indeed,  even  after 
the  acute  anginas.  These  resemble  the  cases  occurring  after  typhus 
fever  and  pneumonia.  In  all  these  cases,  hypersemia  of  the  brain,  and 
occasionally  also  thrombosis  of  the  sinuses,  may  play  an  important  part. 

§  106.  3.  Chronic  constitutional  diseases  very  frequently  cause  the 
develoijment  of  insanity.  Of  these,  we  may  place  in  the  first  series  all 
states  of  weakness  and  of  anasmia  resulting  from  great  loss  of  blood  (in 
childbirth,  for  example),  from  continued  hunger  and  misery,  from  self- 
inflicted  fasting  (religious  asceticism  of  former  times),  after  too  jDrolonged 
nursing;  finally,  in  consequence  of  the  most  various  general  and  local 
maladies  which  impair  digestion,  blood-formation,  and  nutrition.  Anae- 
mia likewise  plays  a  very  important  part  in  the  production  of  a  number 
of  other  neuroses;  and  we  see  that,  even  within  the  limits  of  physiology, 
a  bodily  condition  in  which  the  nutrition  is  lowered  renders  more  easy  a 
state  of  irritation  in  the  functions  of  the  nervous  system,  more  or  less 
disturbance  of  sleep,  etc.  Of  all  purely  physical  causes,  I  might  almost 
attribute  to  these  very  variously  modified  anaemic  states  the  greatest  weight 
in  the  production  of  insanity.  This  view  is  confirmed  by  the  fact  that, 
in  the  great  majority  of  cases,  a  nutrient  and  restorative  treatment  is 
followed  by  the  best  results,  while  an  antiphlogistic  system  of  treatment 
aggravates  the  disease.  It  is  evident  tliat  the  older  physicians  held  the 
same  idea  when  they  spoke  of  the  "asthenic  nature"  of  a  great  many 
mental  diseases. 

The  cases  of  insanity  consecutive  to  acute  diseases  belong,  as  formerly 
remarked,  in  a  great  measure  to  this  category,  likewise  many  cases  of  hysterical 
mental  disease;  the  peculiarities  and  caprices  of  very  chlorotic  individuals 
become  frequently  gradually  developed  to  actual  mental  disorder.  Moreover,  it 
is  quite  uncertain  whether,  in  all  these  cases,  anemia  of  the  brain  is  to  be  con- 
sidered as  the  immediate  determinate  cause  of  the  insanity;  general  anaemia  may 
be  accompanied  by  transient  and  even  persistent  states  of  congestion  of  the  brain, 
and  the  first  is  very  frequently  seen  in  states  of  nervous  and  mental  exaltation. 

Constitutional  syphilis  does  not  readily  lead  to  insanity  otherwise 
than  through  palpable  diseases  of  nutrition  of  the  skull,  of  the  brain  and 
of  its  membranes  :  in  this  relation,  however,  it  merits  very  serious  con- 
sideration. These  diseases  are  periostitis  with  slight  inflammation  of  the 
dura  mater  and  delicate  membranes,  severe  chronic  meningitis  and 
encephalitis  ;  actual  exostoses  of  the  basis  cranii  have  also  been  found  in 
general  paralysis.  Headaches  of  long  standing  with  nightly  exacerbation, 
affection  of  the  nasal  bones,  superficial  tophi  on  the  skull,  and  the  well- 


THE    CAUSES    OF   INSAJfirY.  135 

known  symptoms  of  constitutional  syphilis  in  other  parts  of  the  body, 
render  the  diagnosis  comparatively  simple. 

See  the  article  by  the  author,  "  Diagnost.  Bemerkungen  iiber  Himkrankliei- 
ten"  ('  Archiv  der  Heilk.,'  1860,  i.),  in  which  a  rare  case  of  true  syphilitic  menin- 
gitis with  dementia  is  communicated.  Recently  the  opinion  has  been  advanced, 
that  all  the  cases  of  general  paralysis  of  the  insane  are  to  be  ascribed  to  syphilis 
—a  very  improbable  assumption,  which,  however,  may  do  good  by  causing  in 
future  more  attention  to  be  paid  to  this  important  etiological  circumstance. 

Tulercular  constitutional  disease  appears  likewise  to  be  sometimes  the 
cause  of  the  development  of  insanity.'  Isolated  cases,  considered  as 
cases  of  mental  disease,  even  come  into  asylums  in  which  mental  disorder 
(not  generally,  however,  without  more  or  less  coexisting  motory  affec- 
tion, sometimes  also  vomiting,  etc.)  has  been  caused  by  tubercular  depo- 
sits_  within  the  cranium,  tubercular  meningitis  or  tuberculosis  of  the 
brain-substance  itself,  or  even  by  slight  basilar  meningitis  of  a  somewhat 
protracted  type.^  Cases  of  recent  mental  disease  presenting  indications 
-  of  contraction  of  the  chest,  in  which,  on  examination,  pulmonary  tuber- 
culosis is  discovered,  or  even  only  the  probable  remains  of  formerly 
existing  tubercles,  deserve  in  this  respect  the  most  careful  consideration. 
All  these  cases  terminate  fatally  within  a  short  time.  Ordinarily,  how- 
ever, tuberculosis  and  insanity  stand  in  another  relation  to  each  other, 
and  the  insanity  appears  in  its  ordinary  chronic  forms.  Sometimes 
mental  disorders  appear  at  the  commencement  or  during  the  early  stages 
of  phthisis  pulmonalis,  which  is  frequently  not  discovered.  Even  later, 
concealed  from  the  less  attentive  observer  by  the  symptoms  of  the  mental 
disease,  it  is  hardly  even  recognized  by  the  increasing  marasmus  and 
hectic  fever.  And  of  especial  interest  are  the  cases  in  which,  with  symp- 
toms of  cerebral  congestion,  melancholia  or  mania  occurs  in  individuals 
who  as  yet  present  no  certain  symptoms  of  pulmonary  tuberculosis ;  but 
after  the  mental  disorder  has  existed  for  a  short  time,  distinct  symptoms 
of  phthisis  may  be  recognized  with  which  the  intellect  becomes  more  free 
and  clearer,  and  the  morbid  mental  symptoms  improve  or  altogether 
disappear.  Generally,  in  these  cases  in  which  the  insanity  has  been  cured, 
the  tuberculosis  runs  a  rapid  and  fatal  course  :  nevertheless,  even  here  a 
complete  arrest  (cure)  of  the  tubercular  process  sometimes  takes  place.  ^ 
The  rationale  of  the  production  of  mehtal  disease  in  such  cases  cannot 
well  be  explained.  The  explanations  by  ''crasis"  are  very  properly 
abandoned.  In  other  cases,  also,  the  insanity  appears,  for  the  first  time 
during  the  later  stages  of  confirmed  phthisis,  in  the  form  of  melancholia, 
or  more  frequently  as  maniacal  attacks ;  occasionally  these  make  their 
first  appearance  shortly  before  death.  In  the  more  chronic  cases  of  this 
kind  it  generally  happens  that  the  leading  symptoms  of  the  phthisis,  the 
cough,  expectoration,  etc.,  disappear  on  the  outbreak  of  the  mental 
disease,  and  even  the  nutrition  slightly  improves. 

It  has  not  been  proved  that  the  insanity  which  is  accompanied  by  or 
developed  from  tuberculosis  presents  any  peculiar  character.  Jacob! 
ascribes  to  it  a  certain  capriciousness,  a  whimsical  fluctuation  between 
extremes.     Neumann*  states  that,  from  the  commencement,  depression, 

1  We  shall  afterwards  speak,  in  the  fourth  book,  of  the  occurrence  of  tuber- 
culosis in  asylums  in  those  already  insane.  , 
•^  L.  Meyer,  '  Zeitschrift  fiir  Psychiatric,'  xv.,  1858,  p.  713. 
3  Wiener  Bericht '  (Wien,  1858),  p.  55. 
■*  'Psychiatrie,'p.  162. 


136  THE    CAUSES    OF    INSANITY. 

self-absorption,  great  irritability  and  discontent,  morosity  and  tendency 
to  swear,  are  present,  and  that  at  a  later  period  a  more  gentle  disposition 
is  developed  :  but  these  characteristics  are  by  no  means  constant.  In 
diagnosis,  the  physical  signs,  in  connection  with  any  hereditary  disposi- 
tion, the  history,  etc.,  can  alone  be  employed. 

In  a  case  which  came  under  my  observation,  the  serious  cerebral  affection 
with  prominent  mental  symptoms,  in  an  individual  in  the  last  stage  of  phthisis, 
depended  on  a  large  coagulum  in  the  sinus  (see  '  Diagnost.  Bemerkungen  liber 
Hirnkrankheiten,'  p.  84).  The  clu-onic  insanity  which  is  developed  in  the  way 
which  we  have  described  in  phthisical  persons,  without  palpable  disease  of  the 
brain,  appears  rather  to  be  in  connection  with  the  general  constitutional  disease, 
which  produces,  in  persons  predisposed,  great  nervous  irritability,  perhaps  also 
with  disorders  of  the  circulation  within  the  cranium. 

Pellagrous  insanity  also,  which  is  met  with  especially  in  Northern 
Italy,  and,  according  to  recent  observers,  also  in  certain  parts  of  France 
(Kennes,  Angers,  etc.),  appears  to  depend  upon  a  constitutional  disease 
the  special  cause  of  which  is  still  unknown,  but  which  is  manifested 
particularly  by  an  erythematous  exanthema,  chronic  diarrhoea,  anaemia, 
and  marasmus. 

It  is  perhaps  allowable  to  doubt  the  specific  nature  of  pellagra;  but  I  think  it 
right,  after  the  merely  passing  view  of  it  which  I  obtained  in  the  asylums  of 
Northern  Italy,  to  abstain  from  any  discussion  on  this  subject.  Pellagrous 
insanity,  according  to  Clerici  (1855),  consists  chiefly  in  a,  "vague,  incoherent 
delirium,  accompanied  by  stupor,  loss  of  memory,  and  by  loquacity  without 
special  disorder  of  intelligence  or  violent  excitement;"  the  melancholic  state 
which  predominates  for  a  long  time  always  passes  gi-adually  into  a  state  of  torpor 
of  all  the  mental  powers,  with  muscular  weakness  which  greatly  resembles 
general  paralysis. 

Concerning  the  origin  of  mental  disorders  from  the  special  influence  of  gout, 
nothing  positive  can  be  said.  Cholcemia  appears  to  have  a  great  influence  on  the 
disposition,  and  we  sometimes  see  acute  icterus  gravis  accompanied  by  violent 
delirium  without  any  cerebral  change.  Concerning  the  influence  of  cholaemic 
states  on  the  production  of  chronic  insanity,  no  definite  observations  are  on 
record. 

§  107.  4.  Among  the  chronic  local  disorders  of  the  various  organs,  a 
certain  influence  must  always  be  attributed  to  diseases  of  the  heart, 
although  this  circumstance  does  not  seem  to  act  with  any  special  fre- 
quency. In  the  older  psychological  literature,  the  influence  of  cardiac 
disease  is  evidently  very  much  over-estimated  (Nasse,  1818,  and  others). 
Observation  shows  that  in  the  German  asylums  there  are  not  many  indi- 
viduals with  the  ordinary  heart  affections,  such  as  those,  for  example, 
which  are  produced  in  acute  rheumatism.  Certain  exceptions  are,  indeed, 
more  apparent  than  real.  In  the  interesting  reports  by  Voppel,  of  the 
autopsies  in  the  asylum  at  Colditz,'  for  example,  heart  diseases  appear  in 
rather  high  proportion  ;  but  amongst  these  there  were  a  great  number 
of  aged  patients  who  had  been  long  resident  in  the  asylum,  and  even 
slight  changes  are  there  minutely  noted.  It  may  be  that  many,  even  of 
the  most  severe,  of  these  heart  affections  were  of  long  standing,  and  were 
connected  with  the  production  of  the  insanity  :  for  the  great  majority, 
however,  it  may  certainly  be  assumed  that  they  were  developed  during 
the  existence  of  the  insanity. 

^  In  one  of  these  reports,  of  75  post-mortem  examinations,  13  cases  (16  per 
cent),  in  another  ('  Zeitschrift  fiir  Psychiatrie,'  1855,  xii.,  p.  392),  slight  affections 
of  the  valves  occurred  in  |,  marked  cardiac  disease  in  3V  of  the  cases;  a  third 
report  (Giinsburg,  'Zeitschrift,'  vii.,  1856,  p.  179)  showed  also  a  considerable 
number. 


THE    CAUSES    OF    INSANITY.  137 

The  same  remarks  apply  to  the  statements  of  Tyermann,  who,  in  Cohiey 
Hatch,  found  cardiac  or  valvular  disease  in  }  of  the  female  patients.  Slight 
emotional  irritability  is,  it  is  true,  peculiar  to  many  persons  affected  with  heart 
disease;  but  we  should  not  therefore  conclude  that  these  diseases  have  a  greater 
influence  on  the  development  of  insanity  than  actual  obsei'vation  demonstrates. 
The  diagnosis  of  heart  diseases  in  the  insane  during  life  is  rendered  more  dilScult 
(and  the  statistics  more  uncertain)  by  the  fact  that,  in  states  of  exaltation,  cardiac 
murmurs,  especially  of  the  aortic  valves,  are  very  frequent  without  any  valvular 
deficiency  ('  Wiener  Bericht,'  1858,  p.  58).  Concerning  the  frequency  of  diseases 
of  the  heart,  see  also  tliQ  statistics  given  in  the  Fourth  Book. 

Diseases  of  the  arteries  in  tlie  form  of  the  so-called  arteritis  chronica 
(fatty  degeneration,  atheroma,  calcareous  deposit,  etc.,  etc.)  exert  a  much 
greater  influence;  and  part  of  the  action,  too,  which  is  attributed  to 
heart  diseases  ought  to  be  referred  to  the  arterial  degeneration  which  so 
frequently  accompanies  them.  This  degeneration  causes  disorders  of  the 
circulation  of  the  most  various  kinds — local  ansemia  from  increasing 
diminution  of  the  calibre  of  the  arteries,  encephalitic  inflammation,  and, 
as  it  ajjpears,  various  changes  of  nutrition  of  the  cerebral  substance,  not 
yet  known  in  detail.  Finally,  general  marasmus,  and  the  early  old  age 
which  often  results  from  a  high  degree  of  atheroma  of  all  the  arteries  of 
the  body,  may  contribute  in  a  high  degree  to  the  development  of  men- 
tal disorders.  Atheroma  is  frequently  met  with  in  the  cerebral  arteries 
of  the  insane;  and  even  when  the  larger  vessels  present  no  marked  alter- 
ation, the  minute  branches  ijiay  be  profoundly  degenerate.  Therefore, 
statistics  of  the  diseases  of  the  arteries  of  the  brain  cannot  be  given. 

Amongst  pulmonary  affections,  a  certain  pathogenetic  influence  may 
perhaps  be  attributed  to  empliysema.  It  has  seemed  to  me  in  certain 
cases,  that  the  feeling  of  anxiety  and  melancholia  were  connected 
with  the  oppression  which  this  affection  of  the  lungs  and  its  develop- 
ment can  cause:  nevertheless,  with  the  enormous  frequency  of  emjihy- 
sema,  this  influence,  which  so  rarely  shows  itself,  cannot  be  highly  esti- 
mated; and  even  here  it  is  possible  that  the  emphysema  was  but  a  partial 
symptom  of  a  general  marasmus,  which  was  really  the  important  cause 
of  the  origin  of  the  insanity. 

In  regard  to  diseases  of  the  abdomen,  it  cannot  be  disputed  that  they 
may  give  rise  to  insanity;  but  the  vague  diagnosis  of  the  older  physicians 
— disorders  of  the  abdominal  nerves,  stases  in  the  portal  system,  infarc- 
tus,  hgemorrhoidal  derangements,  etc. — generally  represented  as  of  pri- 
mary importance,  do  not  at  all  assist  us.  We  ought  rather  to  guard  against 
inferring,  without  cause,  from  moderate  disorders  of  digestion  and  of 
the  bowels,  from  the  sensations  produced  by  the  intestinal  contents  re- 
maining too  long  in  the  colon,  the  dark  color  of  the  faeces,  etc.,  the 
existence  of  pathological  states  of  which  a  positive  pathology  knows  noth- 
ing. We  do  not  deny  that  diseases  of  the  liver  may  impede  the  circula- 
tion, and  that  also  those  slight  derangements  of  digestion  may  sometimes 
form  the  media  by  which  especially  the  injurious  influences  of  the  moral 
causes  react  secondarily  upon  the  brain;  and  we  can  admit  with  Brous- 
sais,  as  well  as  the  German  followers  of  the  infarctus  theory,  that  disor- 
ders of  the  bowels,'  especially  catarrh,  maybe,  in  certain  cases,  the  origin- 

'  Willis  narrates  the  remarkable  case  of  a  young  lady  whose  health  had  been 
undermined  by  prolonged  and  severe  grief.  After  having  partaken  of  some  very 
indigestible  pastry,  she  was  suddenly  seized  with  a  burning  sensation  in  the 
cardiac  region;  she  thought  that  the  upper  part  of  her  body  was  in  flames,  and 
ran  into  the  street.  She  had  the  idea  that  she  was  very  wicked,  and  would  be 
dragged  into  hell.  These  ideas  always  returned  when  she  felt  the  sensation  of 
burning.    Jacobi,  loc.  cit.,  p.  667. 


138  THE    CAUSES    OF    INSANITY. 

afcing  causes  of  cerebral  disease,  and  therefore  the  objects  of  treatment. 
Only  it  is  necessary,  on  the  one  hand,  to  insist  upon  a  minute  separation 
of  those  intestinal  disorders  which  appear  as  consequences  of  an  already 
existing  cerebral  disease,  and  those  which  are  really  causes,  on  the  other 
hand,  and  principally  to  urge  a  precise  anatomical  knowledge  and  diag- 
nosis of  these  chronic  diseases.  All  the  various  organic  diseases  of  tlie 
liver,  spleen,  pancreas,  large  and  small  intestine,  ought  not  promiscu- 
ously to  be  ranked  amongst  bilious  diseases;  we  must  remember  that  as 
long  as  a  minute  anatomical  diagnosis  is  not  made  in  each  individual  case, 
we  have  no  certain  basis  on  which  to  found  our  opinion  as  to  etiology  or 
treatment,  and  we  must  not  attribute  too  much  significance  to  the  more 
palpable  but  slight  disorders  of  the  intestinal  canal  (hgemorrhoids,  for 
example),  which  only  cause  the  other  more  important  circumstances  to 
be  overlooked.  In  regard  to  tlie  theory  of  cases  where  changes  in  the 
abdominal  organs  have  been  found  in  the  insane  after  death,  we  must 
refer  to  the  abundant,  especially  the  older  literature  on  this  subject  (for 
example,  the  work  of  Buzorini,  and  the  series  of  dissertations  composed 
at  Bonn  by  Nasse's  pupils);  again  calling  to  mind  the  fact  that  the  sim- 
ple coincidence  of  these  diseases,  without  any  knowledge  of  the  ratio7iale 
of  their  reciprocal  action,  is  not  sufficient  to  enable  them  to  be  considered 
as  causes  of  the  insanity. 

Copro-psychiatrie  [the  secretions  of  the  insane],  which  has  been  developed  as 
a  peculiar  bud  from  the  stem  of  the  "Somatic  School,"  has— partly,  indeed, 
through  the  first  edition  of  this  book — gone  out  of  fashion:  it  may,  nevertheless, 
perhaps  still  have  some  admirers  amongst  the  stragglers  of  the  diagnostic  system. 

The  accounts  of  cases  in  which  mental  diseases  were  caused  by  intes- 
tinal ivorms  (especially  taenia),  and  cured  on  their  removal,  would  be  very 
interesting  and  practically  useful,  if  they  could  only  bear  a  closer  inves- 
tigation. Many  of  these  cases  ajjpear  very  doubtful,  others  seem  rather 
to  refer  to  a  nervous  excitement  maintained  by  anaemia  than  to  actual 
insanity;  in  these  cases,  after  removal  of  the  parasites,  the  nutrition  was 
imj^roved  and  the  functions  of  the  nervous  system  restored. 

The  case  communicated  by  Morel,  '  Etudes  cliniques,'  i. ,  p.  293,  may  be  viewed 
in  this  light. — Esquirol  has  observed  two  cases.  Other  cases  have  been  communi- 
cated by  Girardin,  Ferrus('  Academic  de  Medecine,'  September  23d,  1834),  Wood 
{'Lancet,'  January,  1851),  and  others. — Even  congenital  dementia  is  said  to  have 
been  cured  by  the  expulsion  of  worms  ! 

Diseases  of  the  kidneys  and  the  anomalies  with  which  we  are  as  yet 
acquainted  of  the  urinary  secretion  do  not  appear  to  be  of  great  import- 
ance in  the  etiology  of  mental  diseases.  Some  cases  may  be  mentioned' 
in  which  the  insanity  probably  had  some  connection  with  an  affec- 
tion of  the  kidneys;  but  these  cases  must  be  very  rare,  and  it  is  impos- 
sible to  give  any  particulars  regarding  them.  No  one  would  rank  the 
cerebral  symptoms  in  Bright's  disease  amongst  the  mental  diseases: 
Bright's  disease,  to  which  any  etiological  relation  to  insanity  could  be 
attributed,  is  very  rare  in  the  insane,  although  the  slighter  forms  of  renal 
disease,  so  often  present  in  those  suffering  from  marasmus,  etc.,  are  as 
frequent  in  asylums  (in  general  paralysis,  wasting  diseases,  etc.)  as  else- 
where. 

Neumann  has  related  a  case  of  insanity  which  originated  along  with  diabetes 
{'  Psychiatric,'  p.  163).  In  Addison's  disease  there  is  generally  great  depression 
of  sentiment,  but  no  case  of  actual  mental  disease  is  known  to  me. 

'  Royer,  '  Malad.  des  Reins,'  i.,  1839,  p.  523;  Friedreich,  '  Allgemeine  Patholo- 
gic,' etc.,  p.  402. 


THE    CAUSES    OF    INSANITY.  139 

It  is,  at  all  events,  very  problematic  whether  shin  diseases  have  any 
pathogenetic  influence  on  mental  disorders.  We  have  nowadays  become 
very  sceptical  about  the  older  reports  of  insanity  originating  from  the 
rapid  healing  of  exanthems  or  ulcers  of  the  skin.  General  paralysis  some- 
times commences  with  erysipelas  of  the  scalp,  but  it  is  very  doubtful 
whether  the  exanthem  has  any  connection  with  the  cerebral  disease  which 
succeeds  it. 

§  108.  5.  On  the  contrary,  certain  diseases  of  the  genital  organs, 
and  the  pathological  influences  generally  which  arise  from  them,  have  in 
both  sexes  an  important  influence.  During  the  period  of  sexual  develop- 
ment, particularly  where  there  are  morbid  states  of  these  organs,  insan- 
ity frequently  arises  which  still  presents  the  principal  characters  of  the 
mental  disorders  of  childhood.  There  frequently  occur  in  these  cases 
complications  with  epilepsy,  or  chorea,  or  states  of  somnambulism — cap- 
ricious melancholy,  or  attacks  of  mania  with  suspicion. 

Cases  occur,  but  only  exceptionally,  where  non-satisfaction  of  the 
sexual  functions  and  continence  ought  to  be  considered  as  the  chief  causes 
of  the  insanity.  A  certain  co-operation  of  this  circumstance  is,  however, 
especially  in  the  female  sex,  not  unfrequent,  and  it  may  be  this  which 
gives  a  certain  definite  color  to  develop  insanity,  inasmuch  as  the  long- 
repressed  desire  now  readily  shows  itself  as  amorous  and  sexual  delirium, 
sometimes  ideal,  sometimes  unconcealed. 

In  the  male  sex,  all  those  disorders  of  the  sexual  functions  which  are 
designated  involuntary  seminal  emissions,  pollutio  diurna,  etc.,  are  of 
great  importance.  These  anomalies,  in  which  evidently  the  loss  of  the 
seminal  fluid  is  in  but  few  cases  the  main  point,  frequently  depend,  as 
Lallemand  has  shown,  on  local  diseases  of  the  urethral  mucous  membrane, 
the  seminal  vesicles,  etc. ;  in  other  cases  the  disorder  proceeds  rather  from 
the  nervous  system :  ordinarily,  they  are  preceded  for  a  long  time  by  in- 
creased sexual  irritability  (excessive  pollutions),  which  is  less  a  cause  than 
a  symptom  of  the  already  existing  irritation.  Once  developed,  these 
anomalies  manifest  themselves  by  considerable  decrease  of  the  sexual  feel- 
ings, diminution  of  erection,  impotence,  combined  with  all  possible  kinds 
of  sensitive  and  mental  perversions,  which  sometimes  represent  actual 
hysteria,  sometimes  profound  hyi:)Ochondriasis. 

I,  many  years  ago,  prompted  by  the  writings  of  Lallemand.'  directed  my 
attention  to  this  point  in  a  number  of  insane  male  patients — a  delicate  investiga- 
tion, as  the  patients  are  generally  very  ciuming  in  this  respect,  and  their  state- 
ments are  not  to  be  depended  on :  moreover,  great  caution  is  necessary,  in  order 
not  to  direct  their  attention  too  much  to  this  subject.  In  only  one  case  could  I 
succeed  in  proving  microscopically  the  fact  of  decided  pollutio  dim-na  at  defeca- 
tion ;  but  I  certainly  convinced  myself  that,  in  a  much  greater  number  of  cases 
than  I  had  supposed,  a  diminution  of  the  sexual  sensations  and  desires,  generally 
very  appreciable  to  the  patient,  and  sometimes  also  actual  impotence,  had  for  a 
long  time  preceded  the  development  of  the  insanity.  In  such  cases  it  can  very 
rarely  be  ascertained  with  certainty  whether  these  symptoms  were  the  conse- 
quences of  the  anterior  sexual  excesses  and  abuses,  or  of  the  depressing  emotions 
which  had  also  acted  as  causes  of  the  insanity — whether  they  were  actually  the 
first  symptoms  of  the  melancholic  stage,  or  depended  upon  local  diseases  of  the 
genital  organs.     In  two  instances  where  the  latter  decidedly  appeared  to  be  the 

' '  Des  Pertes  seminales  :'  see  reports  of  cases,  and  '  Resume,'  iii.,  p.  127-200. 
Lallemand's  statements  and  opinions  on  these  points  have  met  with  much  oppo- 
sition, and  in  truth  they  present  many  weak  points.  But  that  which  now  con- 
cerns us,  viz.,  the  fact  that  many  hypochondriacal  and  melancholic  states  are  in 
connection  with  local  disorders  of  the  male  genital  organs,  he  has  well  succeeded 
in  proving. 


14:0  THE    CAUSES    OF    INSANITY. 

case,  I  had  recourse  to  the  treatment  recommended  by  Lallemand,  viz.,  cauteri- 
zation of  the  prostatic  portion  of  the  urethra — in  the  one  case  without  any 
appreciable  influence  on  the  disease,  in  the  other  the  operation  removed  various 
disagreeable  sensations  in  the  genital  organs  of  which  the  patient  complained' 
(sensations  of  constant  currents  of  heat,  etc.),  but  did  not  produce  any  rapid 
favorable  influence  on  the  insanity. 

Lisle  ('  Academic  de  Med.,'  Mars,  1851,  and  in  a  subsequent  work)  has  published 
a  number  of  observations  in  which  mental  disease  appeared  to  originate  from 
spermatorrhoea.  The  insanity  was  specially  characterized  by  the  following 
appearances :— all  kinds  of  chronic  peculiar  and  irregularly  manifested  bodily 
troubles,  melancholic  perversion,  tendency  to  suicide ;  feebleness  of  the  intelli- 
gence, and  especially  of  the  emotions  and  will ;  great  indecision,  etc. :  further, 
remarkable  sensibility,  distrust,  tendency  to  consider  himself  mocked  by  every 
one.  The  microscope  alone  can  confirm  the  diagnosis,  and  all  treatment  is  useless 
so  long  as  the  spermatorrhoea  continues  ;  when  it  ceases,  the  mental  disease  gen- 
erally rapidly  disappears. 

In  the  female  sex,  menstruation  and  all  its  disorders  exercise  great 
influence  on  the  development  and  course  of  mental  diseases.  The  most 
simple,  but  at  the  same  time  the  most  rare,  cases  are  those  where,  in  per- 
sons who  have  been  hitherto  healthy,  there  occurs,  after  sudden  cessation 
or  suppression  of  the  menses,  acute  violent  hyperaemia  of  the  brain,  and 
immediately  therewith  an  outbreak  of  mental  disorder,  generally  mania 
with  active  cerebral  congestion.  More  frequently,  indeed,  the  cessation 
of  the  menses  precedes  the  insanity,  but  does  not  stand  in  so  direct  a  re- 
lation to  it;  it  is  rather  to  be  considered  as  a  result  of  the  persistent 
emotional  depression,  as  a  co-symptom  of  an  existing  anoemic  state,  of 
other  chronic  disease,  or  of  a  generally  depraved  state  of  the  constitution: 
all  which  conditions  are  themselves  more  important  causes  than  the  me- 
tastasis. On  the  other  hand,  menorrhagia  resulting  from  antemia  and 
general  lowering  of  the  nutrition  may  be  a  cause  of  insanity  as  well  as  of 
any  other  neurosis.  Frequently,  however,  irregularities  of  menstruation 
first  appear  with  the  commencement  of  the  mental  disease,  in  the  same 
manner  as  they  may  occur  in  any  other  chronic  disease;  and  we  may  also 
frequently  observe  during  recovery  from  insanity  that  it  does  not  follow 
upon  the  return  of  the  menses,  but  the  reverse— the  return  of  the  menses 
follows  upon  the  already  accomplished  cure  of  the  mental  disease.  When 
menstruation  continues  during  the  mental  disease,  as  it  often  does  with- 
out the  least  derangement,  it  is  not  unusual  to  observe,  with  each  return 
of  the  period,  increased  excitement,  general  increase  of  the  mental 
disorder.  In  rare  instances,  insanity  simply  periodic,  lasting  during  the 
menstrual  period  with  complete  lucid  intervals  of  several  weeks'  duration, 
has  been  observed. 

The  period  of  the  first  appearance  of  the  menses  often  brings  with  it,  together 
with  headache  and  all  sorts  of  nervous  affections,  disturbances  of  the  feelings  and 
emotions  which  may  proceed  to  delirium  and  to  mania.  Still  more  frequently 
the  latter  occurs,  or  other  forms  of  insanity  appear  (as  melancholia  w-ith  stupor, 
suicide),  in  cases  where  menstruation  is  for  a  long  time  morbidly  retarded,  or 
even  has  not  appeared  ;  some  cases  of  the  kind  pass  in  incurable  insanity  or 
dementia.  It  is  well  known  that  most  females  are  very  sensitive,  very  peevish 
and  nervous,  at  the  menstrual  periods.  All  causes  of  disease,  especially  moral 
causes,  act  more  powerfully  at  these  times;  and  in  many  persons  who  enjoy 
perfect  health  during  the  intervals,  there  may  be  observed,  during  the  periods,  a 
perversion  of  sentiment  bordering  on  disease,  sadness,  hypochondria,  or  capricious- 
ness.     In  many  of  the  insane,  the  mental  disease  becomes  increased  in  these  times, 


1  Cooper,  in  his  Lectures,  mentions  a  case  in  which  a  large  number  of  prostatic 
calculi  were  removed  by  means  of  operation.  These  calculi  did  not  only  cause 
pain,  but  a  continuous  emotional  excitement  bordering  on  insanity. 


THE    CAUSES    OF    INSANITY.  141 

sometimes  to  mania,  sometimes  to  nymphomaniacal  forms  accompanied  by  cere- 
bral congestion,  and  suicidal  patients  require  to  be  carefully  watched.  These 
should  be  considered  as  cases  of  nervous  irritation  of  the  brain  proceeding  from 
the  genital  organs  ;  if  the  loss  of  blood  has  been  profuse,  the  irritation  will  be  the 
more  increased.  The  connection  between  the  menstrual  disorder  and  the  insanity 
appears  to  be  most  intimate  in  those  cases  of  suppression  of  the  menses  which  we 
mentioned  first  of  all.  Here,  too,  recovery  takes  place  with  the  return  or  regu- 
lation of  menstruation,  and  here  alone  is  appropriate  emmenagogue  treatment 
indicated  and  necessary  :  to  this  category  alone  belong  also  those  rare  cases  in 
which  recovery  from  the  insanity  occurs  immediately  after  the  return  of  the 
menses.  Dysmenorrhoea  is  ordinarily  accompanied  by  those  nervous  affections 
which  are  understood  by  the  name  hysteria  ;  these  are  often  principally  cerebral. 
The  period  of  the  cessation  of  the  menses  often  exercises  a  very  favorable,  even 
occasionally  a  curative,  influence  on  the  existing  mental  disease  :  more  frequently, 
however,  it  exerts  an  unfavorable  influence,  so  that  the  hitherto  more  variable 
and  irritable  forms  become  fixed,  and  pass  into  chronic  mania  and  dementia. 
Those  cases  also  which  make  their  first  appearance  at  this  time  of  life,  often 
melancholia,  are  generally  of  an  unfavorable  character. 

The  influence  of  menstruation  is  treated  of  in  two  excellent  recent  papers  : 
Brierre,  '  Annales  Med.  Psychol.,'  1851,  iii.,  p.  574,  and  Schlager,  '  Zeitschrift  fi'ir 
Psychiatrie,'  xv.,  1858,  p.  457  (this  paper  may  also  be  found  in  the  Report  of  the 
Vienna  Asylum,  Wien,  1858,  p.  140). 

The  local  diseases  of  the  uterus,  ovaries,  and  vagina  (ovarian  cysts, 
displacements  of  the  uterus,  uterine  catarrh,  ulcers  of  the  cervix,  etc.) 
are  generally  followed  in  the  first  place  by  well-marked  hysteria,  which 
then  may  gradually  pass  into  insanity.  This  insanity  often  presents  dis- 
tinct traces  of  its  origin  in  its  general  hysterical  character,  or  in  certain 
morbid  conceptions  (for  example,  the  idea  of  pregnancy). 

Whether  it  be  the  case  or  not,  the  possibility  of  the  existence  of  such  local 
disease  in  female  patients  ought  always  to  be  kept  in  view,  and  on  the  least  sus- 
picion a  minute  examination  should  be  made.  It  is  certainly  of  great  detriment 
to  the  patients  that  there  exists  at  the  present  time  amongst  asylum  physicians  a 
truly  childish  delicacy  in  regard  to  vaginal  examinations  and  the  use  of  the 
speculum.  In  Germany,  France,  and  England,  I  have  found  the  same  delicacy  ; 
they  seem  afraid  of  exciting  the  patients,  of  awakening  or  increasing  certain 
delirious  ideas,  just  as  long  ago.  for  similar  reasons,  they  were  afraid  to  auscul- 
tate :  such  subordinate  consideration  ought  not  to  be  regarded  when  it  interferes 
with  what  is  the  only  means  of  arriving  at  a  correct  diagnosis,  and  therefore  a 
proper  system  of  treatment.  The  light  which  we  gain  by  the  speculum,  and 
which  so  frequently  elucidates  hysteria,  can  alone  clear  up  much  in  connection 
with  that  insanity  which  is  so  closely  aUied  to  hysteria  !  I  have  myself  observed 
in  private  practice  certain  very  successful  cases  of  recovery  from  hysterical 
insanity  by  means  of  local  treatment  of  the  genital  organs,  after  all  other  means 
had  failed.  Brosius  ('  Med.  Centralzeitung,'  1858,  27)  relates  two  cases  of  recovery 
from  simple  acute  melancholia  in  consequence  of  local  treatment  of  diseases  of 
the  genital  organs.  Flemming  ('  Psychosen,'  p.  194)  saw  two  cases  in  which  pro- 
lapsus uteri  accompanied  by  frequent  haemorrhages  gave  rise  to  attacks  of  rage 
and  maniacal  excitement,  which  ceased  when  the  prolapsus  was  permanently 
retained  by  means  of  a  pessary  ;  in  one  case  the  untimely  removal  of  the  pessary 
was  followed  by  a  return  of  the  mental  disorder.  Concerning  uterine  displace- 
ments as  causes  of  insanity,  see  the  remarks  of  L.  Meyer,  Virchow's  '  Archiv,' 
ix.,  p.  108. 

§  109.  But  of  all  the  influences  which  arise  from  the  female  sexual 
system,  pregnancy,  and  still  more  the  imerperal  state  and  lactation,  are 
the  most  important.  Of  these,  pregnancy  is  most  rarely  followed  by  de- 
veloped insanity  in  the  form  of  profound  melancholia  or  mania;  more 
frequently  it  causes  merely  a  state  of  moderate  depression,  which  is  some- 
times evidently  the  first  stage  of  subsequent  puerperal  mania.  The 
direct  moral  influences,  especially  the  various  emotions,  which  accompany 
a  first  pregnancy,  may  be  of  great  importance  in  those  previously  disposed 


14:2  THE    CAUSES    OF    INSANITY. 

to  insanity.  An  influence  not  less  great  ought  in  other  cases  to  be  as- 
cribed to  the  states  of  congestion  and  of  anasmia  which  are  so  frequently 
developed  during  pregnancy. 

Slight  mental  disorders,  hysterical  humors,  irresistible  longings,  foolish 
jealousy,  and  kleptomania,  are  during  pregnancy  more  frequent  than  fully  devel- 
oped insanity.  Cases  occur  in  which  the  mental  disorder  appears  in  a  certain 
form  in  each  pregnancy  ;  on  the  contrary,  cases — I  myself  know  of  one,  and 
Guislain  ('  Legons  oraleo,'  ii.,  p.  275)  mentions  one— in  which  an  existing  slight  or 
severe  mental  affection  disappeared  during  each  pregnancy,  so  that  the  individuals 
were  in  possession  of  their  reason  only  when  they  were  pregnant.  We  may  assume 
that  in  such  cases  the  cerebral  disease  is  sympathetic,  dependent  upon  some 
(slight)  probably  mechanical  affection  of  the  generative  organs,  which— and  with 
it  the  evil  influence  which  it  exercises  on  the  cerebral  functions — always  dis- 
appears when  conception  takes  place.  Insanity  may  also  commence  during  the 
first  months  of  pregnancy,  more  frequently  it  makes  its  first  appearance  in  the 
latter  months  ;  it  occasionally  disappears  with  the  delivery,  or  it  may  be  not  till 
a  later  period,  till  the  return  of  the  menses,  but  we  cannot  calculate  with  certainty 
on  this  being  the  case— it  may  also  continue  and  become  incurable.  When  one 
who  is  already  insane  becomes  pregnant,  it  is  only  very  expectionally  that  it 
exerts  a  favorable  influence  on  the  insanity ;  and  this  can  only  be  expected  in 
recent  cases,  and  such  as  depend  on  diseases  of  the  generative  organs  themselves. 
Sometimes  the  existing  insanity  ceases  with  conception,  but  returns  after  de- 
liver5\  Most  commonly  the  mental  disease  is  only  rendered  worse,  and  incura- 
bility accelerated.  See  Marce,  '  De  la  Folie  des  Femmes  enceintes,'  etc.,  PariS; 
1858. 

Even  during  delivery,  and  from  that  time  during  the  whole  course  of 
the  puerperal  state,  severe  mental  disorders  may  arise,  the  comprehension 
of  which  under  the  term  puerperal  insanity,  according  to  the  form  of  the 
insanity,  does  not  seem  to  be  very  correct,  as  they  have  in  regard  to  symp- 
toms both  something  altogether  distinct  from  ordinary  insanity,  and 
amongst  themselves  possess  many  peculiarities  in  common:  still,  in  re- 
lation to  the  peculiar  circumstances  of  the  origin,  the  term  is  quite  justi- 
fiable. In  a  practical  point  of  view,  a  minute  separation  of  these  cases  is 
always  necessary. 

During  the  act  of  delivery,  there  occasionally  occur  states  of  great  ex- 
citement and  mania";  indeed,  it  has  even  been  observed  that  with  each  pain 
there  occurred  a  violent  outbreak  of  fury.  The  pain,  the  very  great 
general  nervous  excitement,  and  the  evident  congestive  states,  lie  at  the 
foundation  of  these  disorders;  tliey  occasionally  manifest  themselves  in 
great  enmity  towards  the  child  (sometimes  killing  it),  do  not  continue 
for  longer  than  a  few  hours  or  a  day,  and  are  very  important  in  a  medico- 
legal point  of  view. 

Amongst  the  mental  disorders  which  appear  subsequently  to,  but 
generally  within  fourteen  days  after  delivery,  the  one  may  be  considered 
as  the  symptomatic  delirium  of  other  serious  puerperal  diseases^— endome- 
tritis, phlebitis  and  pygemia,  consecutive  endocarditis  (PKiwisch),  etc.; 
cases  in  which  the  cerebral  affection  ought  to  be  ascribed  partly  to  the  inju- 
rious effect  of  the  purulent  infiltration,  partly  to  the  evident  cerebral  con- 
gestion— in  Avhich  the  mental  disorder  shares  the  (critical)  prognosis  of  the 
principal  disease,  in  general  it  persists  or  ceases  with  it;  in  certain  cases, 
however,  it  may  continue  for  a  long  time  after  recovery  from  the  puer- 
peral fever. 

In  another  series  of  cases,  on  the  contrary,  insanity  is  developed  with- 
out the  existence  of  any  other  serious  puerperal  disease;  a  cerebral 
disease  which,  independent  from  the  commencement,  is  either  in  the 
form  of  melancholy,  especially  of  raptus  melancholicus,  or,  especially  if  a 


THE    CAUSES    OF   INSANITY.  143 

state  of  mental  depression  has  existed  during  pregnancy,  or  one  of  excite- 
ment, and  frequently  of  nymphomaniacal  delirium.  These  are,  above 
all,  the  cases  Avhich  afterwards  pass  into  persistent  insanity — of,  however, 
on  the  whole,  not  unfavorable  prognosis.  They  appear  particularly  in 
individuals  already  predisposed  under  the  influence  of  all  kinds  of  de- 
termining causes,  of  which  the  depressing  emotions,*  on  the  one  hand, 
and  anaemia,  owing  to  great  hasmorrhage  during  delivery,  operations,  etc., 
on  the  other,  are  evidently  the  most  important. 

The  first  symptoms  of  the  mental  disorder  in  cases  of  the  latter  kind  appear 
sometimes  very  soon  after  the  birth  of  the  child,  or  on  the  third  or  fifth  day  with 
the  milk  fever;  most  frequently,  at  all  events,  in  the  first,  then  in  the  second 
week — at  latest  four  weeks  after  delivery.  Great  loss  of  blood,  likewise  emotions, 
are  often  the  exciting  cause;  hereditary  pi-edisposition,  great  nervous  irritability, 
great  emotional  susceptibility  during  pregnancy,  from  important  predisposing 
circumstances  (Reid  in  Bedlam— 1848— found  in  111  cases  of  puerperal  insanity, 
hereditary  predisposition  in  45).  The  most  frequent  forms  are  maniacal  excite- 
ment, then  melancholia  (frequently  attonita). 

Amongst  131  cases  in  Bedlam  (Webster),  tendency  to  suicide  existed  in  41  (31 
per  cent);  in  mania  the  prognosis  is  more  favorable  than  in  melancholia.  On  the 
whole  the  prognosis  of  puerperal  insanity  is  very  properly  considered  as  relatively 
favorable  ;  still,  the  curability  of  this  form  is  frequently  over-estimated  :  in  Bed- 
lam, of  181  cases,  81  were  cured  (41.83  per  cent),  while  during  a  space  of  twenty 
years  in  the  same  asylum  the  proportion  of  recoveries  from  insanity  in  general 
was  53.67  per  cent  (Webster).  Recovery  occurs  most  frequently  within  the  first 
three  months  ;  sometimes  we  see,  under  the  symptoms  of  puerperal  rnania,  an 
already  existing  tuberculosis  proceed  with  great  rapidity  after  childbirth,  and 
terminate  in  death.  Simpson  ( 1853)  thought  it  probable  that  the  use  of  chloroform 
m  obstetric  practice  might  prove  a  prophylactic  against  puerperal  insanity.  Not 
only  has  this  assumption  not  been  confirmed,  but  cases  have  occurred  in  which 
the  use  of  chloroform  appeared  to  determine  the  outbreak  of  the  mental  disease 
(Webster). 

See  Esquirol, '  Maladies  Mentales,'  i.,  cap.  5  ;  Schneider,  '  Ueber  Mama  lactea," 
inNasse's  '  Zeitschrift  fiir  Anthrop.,'  1823.  p.  163;  Neumann,  'Krankheiten  des 
Vorstellungsvermogens,'  1822,  cap.  14  ;  Kiwisch  v.  Rotterau.  '  Die  Krankheiten 
der  W6chnerinnen,'ii.,  1841.  p.  228;  Helm,  'Monographic  der  Puerperalkrank- 
heiten,'  1840,  §§  28,  46,  53,  75 ;  Sinogowitz,  '  Die  Geistesstorungen,'  1843,  §  25  ; 
Leubuscher,'  '  Verhandl.  der  Gesells.  fur  Geburtshiilfe,'  Berlin,  1846,  p.  94; 
Macdonald,  '  American  Journal  of  Insanity,'  iv.,  1847,  p.  113  ;  Webster,  'Journal 
of  Psychological  Medicine,'  1849  ;  Ideler,  "  Die  Vesania  puerperalis,"  '  Charite 
Annalen,'  ii.,  1,  1851,  p.  122;  Weill,  'Consid.  sur  la  Folie  puerperale,'  Diss., 
Strasb.,  1851  ;  Marce,  '  Traite  de  la  Folic  des  Femmes  enceintes,'  Paris,  1858. 

Finally,  as  to  the  influence  of  ladatmi,  it  is  well  known  that  weaken- 
ing of  the  constitution  through  prolonged  nursing  is  a  cause  of  all  possi- 
ble forms  of  severe  neuroses;  and  it  is  especially  severe  or  persistent  emo- 
tionsv  moral  predispositions,  etc.,  which  give  rise  to  this  form  of  cerebral 
affection — puerperal  insanity. 

From  this  enumeration  of  the  causes  of  insanity,  the  general  doctrine 
may  have  been  deduced  that  everything  which  lowers  the  nutrition,  all 
true  states  of  weakness,  and  further  that  all  circumstances  which  over- 
excite  the  nervous  system,  which  favor  congestion  of  the  nervous  centres 
—in  short,  all  which  has  as  a  result  the  development  and  fixing  of  the 
nervous  constitution,  may  become  causes  of  insanity.  We  shall  again 
revert  to  this  subject  when  we  come  to  speak  of  the  treatment  of  mental 
diseases. 


"See  Esquirol,  i.,  pp.  141,  142. 


144  rOKMS    OF    MENTAL    DISEASE. 


BOOK  THIED. 

FOEMS  OF  MENTAL  DISEASE. 


§  110.  A  CLASSIFICATION  of  mental  diseases  according  to  their  nature 
— that  is,  according  to  the  anatomical  changes  of  the  brain  which  lie  at 
their  foundation — is,  at  the  present  time,  impossible  (§  6).  But,  as  the 
whole  classification  of  mental  diseases  is  merely  a  symptomatological  one, 
so  that  we  recognize  the  different /orms  of  insanity  only  by  their  present- 
ing different  groups  of  symptoms,  instead  of  the  anatomical  principle  of 
division,  we  must  adopt  the  functional,  the  physiological;  and  this  is — as 
the  disorders  of  the  understanding  and  will  are  the  principal  and  the  most 
striking — also  a  psychological  basis.  Insanity  is,  therefore,  to  be  divided 
according  to  the  form  and  nature  of  the  psychical  anomalies.  But 
whilst  it  is  the  aim  of  clinical  instruction  to  render  conspicuous  and  to 
analyze  the  multiplicity  of  mental  disorders  in  the  concrete,  nosology 
must  content  itself  with  establishing  fewer  principal  groups  of  mental 
disorders,  fewer  fundamental  ahiormal  states,  which  result  from  the 
agreement  of  a  great  number  of  cases  in  certain  characteristic  signs,  and 
to  which,  therefore,  all  the  varieties  of  individual  cases  may  be  referred. 
It  is  these  fundamental  conditions  and  their  symptoms  that  we  have  here 
principally  to  describe;  and  although  all  the  varieties  which  they  may 
present  and  their  reciprocal  transformations  must  indeed  be  considered, 
our  limits  do  not  permit  us  to  enter  into  exhaustive  details.  Even  that 
fusion  of  normal  and  abnormal  mental  appearances  on  which  the  varieties, 
intermediate  states,  and  transitions  depend,  constitutes  one  of  the  most 
interesting  objects  of  clinical  study.  It  cannot,  however,  be  minutely 
followed  in  the  short  expositions  of  a  text-book. 

The  analysis  of  observations  leads  to  the  conclusion  that  there  are  two 
grand  groups  or  fundamental  states  of  mental  anomalies,  which  represent 
the  two  most  essential  varieties  of  insanity.  In  the  one,  the  insanity 
consists  in  the  morbid  production,  governing,  and  persistence  of  emotions 
and  emotional  states,  under  the  influence  of  which  the  whole  mental  life 
suffers  according  to  their  nature  and  form.  In  the  other,  the  insanity 
consists  in  disorders  of  the  intellect  and  will,  which  do  not  (any  longer) 
proceed  from  a  ruling  emotional  state,  but  exhibit,  without  profound 
emotional  excitement,  an  itidependejit,  tranquil,  false  mode  of  fJwught 
and  of  will  (usually  with  the  predominant  character  of  mental  weakness). 
Observation  shows,  further,  that  in  the  great  majority  of  cases,  those 
conditions  which  form  the  first  leading  group  precede  those  of  the 
second  group;  that  the  latter  generally  appear  only  as  consequences 


FORMS    OF    MENTA.L    DISEASE.    •  145 

and  terminations  of  the  first,  when  the  cerebral  affection  has  not  been 
cured.  There  is,  moreover,  again  presented  within  the  first  group,  in  a 
great  proportion  of  cases,  a  certain  definite  succession  of  the  various 
forms  of  emotional  states,  whence  there  results  a  method  of  viewing  in- 
sanity which  recognizes  in  the  different /orm.s%  different  stages  of  one 
morbid  process;  which  may,  indeed,  be  modified,  interrupted,  or  trans- 
formed by  the  most  varied  intercurrent  pathological  circumstances,  but 
which,  on  the  whole,  pursues  a  constantly  progressive  course,  which  may 
proceed  even  to  complete  destruction  of  the  mental  life.  By  means  of 
this  knowledge,  most  distinctly  expressed  by  Zeller,  it  is  now  possible, 
from  the  nature  of  the  symptoms,  to  approach  much  more  closely  to  the 
problem  (which  ouglit  always  to  occupy  the  foreground)  of  an  anatomico- 
pathological  knowledge  and  diagnosis  of  mental  diseases. 

Pathological  anatomy  shows  us,  even  at  present,  that  in  the  first  group, 
or  in  the  first  stages  of  insanity,  it  is  rare  to  find  important  organic  altera- 
tions, or  such  as  are  not  capable  of  complete  removal;  whilst  in  the 
second  group,  or  in  the  terminal  stages,  very  often  there  exist  palpable 
organic  changes  which  are  incapable  of  cure — particularly  atrophy  of  the 
brain  more  or  less  extensive,  with  oedema  of  the  membranes,  and  chronic 
hydrocephalus.  We  may  say,  then,  that  those  cerebral  lesions  which 
give  rise  to  the  first  stages  of  insanity — lesions  which  are  certainly  not 
always  of  an  identical  nature,  and  which  we,  as  yet,  cannot  generally 
characterize  anatomically — have  this  in  common,  that  they  terminate  in 
very  many  cases  in  those  characteristic  consecutive  changes  in  the  brain 
which  we  have  spoken  of  as  a  stage  of  permanent  anatomical  lesions. 

Consequently,  the  simple  symptomatological,  the  psychologico-analy- 
tical  method,  and  the  anatomical  manner  "of  investigation,  come  all  to 
the  same  practically  important  conclusion,  that  insanity  is  a  curable  dis- 
ease only  so  long  as  it  is  confined  to  the  first  group  of  primitive  (emo- 
tional) mental  disorders,  and  that  it  becomes  incurable  with  the  develop- 
ment of  the  secondary  lesions  which  constitute  the  second  group.  That 
first  series  includes  the  forms  of  melancholy,  mania,  and  monomania; 
the  second,  the  forms  of  chronic  mania  and  dementia. 

'  "Zeit.  Bericht,  etc.;"  '  Med.  Correspondenzbl.,'  Juli,  1840. 
10 


146  BTAXEB    OF    MENTAL    DEPRESSION. 


CHAPTER  I. 
STATES  OF  MENTAL  DEPRESSION— MELANCHOLIA. 

§  111.  The  fundamental  affection  in  all  these  forms  of  disease  con- 
sists in  the  morbid  (§  37)  influence  of  a  painful  depressing  negative  affec- 
tion— in  a  mentally  painful  state.  This  state  may,  at  the  outset,  in  the 
simplest  and  the  most  primitive  form  of  melancholia,  continue  in  the 
form  of  a  vague  feeling  of  ojipression,  anxiety,  dejection,  and  gloom; 
generally,  however,  this  obscure  vague  feeling  of  annoyance  passes  into 
a  single,  concrete,  painful  perception;  there  arise  thoughts  and  opinions 
in  harmony  with  the  actual  disposition  of  mind,  and  without  external 
motive  (false  ideas) — a  veritable  delirium,  revolving  constantly  upon  some 
tormenting  and  painful  subject,  while  at  the  same  time  the  intellect  pre- 
sents some  anomalous  forms,  is  restrained  in  the  exercise  of  its  freedom,^ 
becomes  slow  and  sluggish,  and  the  thoughts  monotonous  and  vacant. 
The  normal  reaction  towards  the  external  world  is  either  weakened  and 
blunted  (mental  anaesthesia,  indifference  even  to  actual  stupor),  or 
exaggerated  in  such  a  manner  that  all  mental  impressions  are  painful 
(mental  hyperaesthesia) ;  and  very  often  tliese  two  forms  are  found 
in  the  same  patient  alternating  with  each  other.  Many  disorders  of  the 
emotion  and  of  the  will  are  moreover  associated  with  this.  Their  varie- 
ties form  a  basis  for  the  distinction  of  the  several  principal  forms  of 
melancholia.  Sometimes  volition  is  directly  diminished  and  weakened, 
at  other  times  it  is  convulsively  restricted  (absence  of  energy  and  of  will); 
at  others  there  appear  certain  desires  and  impulses  of  will  to  which  mate- 
rial and  object  are  afforded  by  the  morbid  mind;  or,  lastly,  a  high  degree 
of  moral  pain  excites  various  impulses  of  an  aimless  convulsive  character, 
which  manifest  themselves  in  extreme  restlessness,  the  continuance  and 
increase  of  which  cause  these  forms  of  melancholia  to  assume  a  different 
character,  and  to  pass  into  quite  another  variety  of  that  of  mania. 

In  employing  the  term  "  states  of  mental  depression,"  we  do  not  wish  to  be 
understood  as  implying  that  the  nature  of  these  states  or  conditions  consists  in 
inaction  and  weakness,  or  in  the  suppression  of  the  mental  or  cerebral  phenomena 
which  accompany  them.  We  have  much  more  cause  to  assume  that  very  violent 
states  of  irritation  of  the  brain  and  excitation  in  the  mental  processes  are  here 
very  often  the  cause  ;  but  the  general  result  of  these  (mental  and  cerebral)  pro- 
cesses is  depression  or  a  painful  state  of  mind.  It  is  sufficient  to  recall  the  analogy 
to  physical  pain,  and  to  those  who  imagine  that  they  make  things  better  by  sub- 
stituting "cerebral  torpor"  and  "cerebral  irritation"  for  "depression"  and 
"  exaltation,"  it  may  fairly  enough  be  objected  that  in  melancholia  there  is  also 
a  state  of  irritation. 

Observation  shows  that  the  immense  majority  of  mental  diseases  com- 
mence with  a  state  of  profound  emotional  perversion,  of  a  depressing  and 
sorrowful  character.  Guislain  was  the  first  to  elucidate  this  highly  inter- 
esting fact,  and  make  it  at  all  serviceable.  Of  its  general  correctness 
there  is  no  doubt,  and  we  can  have  no  hesitation  in  speaking  of  the  "  sfn- 
dium  melancholicum"  as  the  initiatory  period  of  mental  disease.     Of 


STATES    OF    MENTAL    DEPRESSION.  147 

course  there  are  exceptions.'  Thus,  in  senile  dementia,  in  periodic 
mania,  in  meningitis,  in  the  mental  diseases  consecutive  to  typhus  fever, 
l)neumonia,  cholera,  sun-stroke,  etc.,  the  outbreak  of  mania  is  generally 
observed  without  being  preceded  by  melancholia;  but  the  cases  are  much 
more  frequent  in  which  this  stadium  melancholicum  only  appears  to  be 
absent  because  it  was  less  intense,  and  was  not  then  recognized  as  a  stage 
of  mental  disease. 

The  "  stadium  melancholicum"  which  precedes  insanity  is  by  some  physicians 
designated  as  the  period  of  incubation,  or  "prodromal  stadium ;"  and,  in  their 
opinion,  the  outbreak  of  the  disease  dates  only  from  the  time  wlien  the  patient  is 
no  longer  able  to  control  his  actions.  This  limitation  is  to  a  certain  extent  arbi- 
traiy,  but  the  circumstance  that  the  stage  of  incubation  has  almost  always  a 
depressive  character  is  interesting  and  of  great  importance. 

The  melancholia  which  precedes  insanity  sometimes  appears  exter- 
nally as  the  direct  continuation  of  some  painful  emotion  dependent  upon 
some  objective  cause  (moral  causes  of  insanity),  e.  g.,  grief,  jealousy;  and 
it  is  distinguished  from  the  mental  pain  experienced  by  healthy  persons 
by  its  excessive  degree,  by  its  more  than  ordinary  protraction,  by  its 
becoming  more  and  more  independent  of  external  influences,  and  by  the 
other  accessory  affections  which  accompany  it  (see  further  on).  In  other 
cases  the  melancholia  originates  without  any  moral  cause,  though  most 
frequently  there  are  such,  but  it  does  not  originate  as  their  direct  con- 
tinuation, but  only  shows  itself  after  these  affections  have  wrought  con- 
siderable disturbances  in  the  functions  and  nutrition  of  the  nervous  sys- 
tem, or  have  undermined  the  entire  constitution.  ,  .       ^ 

Section  I. — Hypochondriasis. 

§  112.  The  hypochondriacal  states  represent  the  niiildest,  most  mod- 
erate form  of  insanity,  and  have  many  peculiarities  which  essentially 
distinguish  them  from  the  other  forms  of  melancholia.  _  While  they,  of 
course,  share  with  the  others  the  generic  character  of  dejection,  sadness, 
depression  of  mind,  diminution  of  the  activity  of  the  will,  and  of  a  delir- 
ium which  corresponds  to  this  mental  disposition,  they  yet  differ  from 
them  in  this  characteristic  manner — that  in  these  states  the  emotional 
depression  proceeds  from  a  strong  feeling  of  bodily  illness  which  con- 
stantly keeps  the  attention  of  the  patient  concentrated  upon  itself;  that, 
consequently,  the  false  opinions  relate  almost  exclusively  to  the  state  of 
health  of  the  subject,  and  the  delirium  turns  constantly  upon  apprehen- 
sions of  some  grave  malady^upou  unfounded  and  curious  ideas  regard- 
ing the  nature,  the  form,  and  the  danger  of  this  his  disease.  This  feel- 
ing of  bodily  illness  is  sometimes  general  and  vague,  sometimes  it  resolves 
itself  into  particular  anomalous  and  disconnected  sensations.  It  often 
depends  on  irritation  of  the  nervous  centres  arising  from  peripheral  dis- 
ease— often  very  obscure  and  concealed — of  the  viscera.  It  is  also  fre- 
quently provoked  centrally  under  the  direct  influence  of  moral  causes — 
e.  g.,  reading  medical  books,  frequent  contact  with  hypochondriacs. 

These  morbid  sensations  are  always  increased  through  the  direction 
of  the  attention  to  them;  and  when  the  disease  has  attained  a  certain  de- 


'  Guislain  himself  knew  of  such  exceptions  ('  Leg.  orales.'  ii.,  p.  162)  ;  and  he 
compares  them  to  cases  of  intermittent  fever,  where  the  cold,  hot,  and  sweating 
stages  did  not  follow  precisely  the  usual  course. 


148  STATES    OF    MENTAL    DEPRESSION. 

gree  of  development,  such  may,  through  direction  of  the  attention  to  this 
or  that  organ,  be  awakened,  dispkced,  and  called  forth  anew  in  each 
organ  of  the  body  in  succession.  As  to  the  part  which  the  intellect  plays 
in  this  disease,  it  may  be-  said  that,  in  spite  of  this  emotional  disorder 
and  of  the  false  conceptions,  the  association  of  ideas  is  usually  unimpaired; 
the  abnormal  sensations  and  ideas  are  logically  connected  throughout: 
and  justified  by  reasons  which  are  still  within  the  bounds  of  possibility. 
And  just  because  of  this  absence  of  actual  derangement  of  the  under- 
standing, hypochondria  appears  to  be  essentially  afolie  raisonminte  me- 
lanchoUque,  the  antithesis  of  which — the  ordinary  so-called  monomania- 
^Blfolie  raisonnante — we  shall  in  find  the  states  of  mental  exaltation. 

We  recommend  the  thinking  and  intelligent  reader  to  verify  for  himself  the 
analogy  which  results  from  the  comparison  of  these  two  forms  of  the  morbid 
states  and  feelings.  Hypochondria  reaUy  finds  no  other  suitable  place  in  nosology 
than  among  mental  diseases,  among  which  Sauvages  and  CuUen  have  long  ago 
ranged  it,  and  since  then  Pinel,  Georget,  and  Falret.  It  is  also  the  natural  con- 
sequence of  the  symptomatology  of  the  affection.  It  is  a  perversion  of  sentiment 
which  may  go  to  the  slightest  or  the  most  extreme  degrees  without  essentially 
changing  the  character.  The  hypochondriac,  it  is  true,  may  reason  correctly- 
setting  out  from  false  premises  ;  but  this  does  not  in  the  least  invalidate  the  fact 
that  hypochondria  is  a  mental  affection,  any  more  than  that  because  hypochondria 
often  accompanies  or  complicates  various  chronic  diseases  seated  in  different 
organs,  it  ought  on  that  account  to  be  identified  or  confounded  with  these  dis- 
eases. 

§  113.  Symptojns. — The  disposition  of  the  patient  begins  to  change 
without  any  assignable  cause.  He  becomes  dejected,  peevish,  suspicious, 
exhibiting  more  extreme  sensibility  and  a  disposition  to  connect  every- 
thing with  himself.  Everything  wearies  him,  and  he  is  very  easily  fa- 
tigued. At  the  commencement,  this  state  experiences  many  remissions; 
and  the  paroxysms  assume  the  form  of  an  irritable,  restless,  and  distrust- 
ful disposition,  or  of  a  mental  apathy,  which  may  go  so  far  as  to  pro- 
duce weariness  of  life,  or  anxiety  which  may  proceed  to  despair  and  loss 
of  self-control.  An  undefined  yet  vivid  feeling  of  illness  torments  and 
annoys  the  patient  in  an  obscure  sort  of  manner.  All  the  parts  of  the 
sensory  nervous  system  may  be  the  seat  of  morbid  sensations,  often  very 
painful  (formication,  heat  and  cold,  crawling  about  of  a  foreign  body — 
as  if  his  head  would  burst — as  if  he  were  empty,  dead,  pierced,  torn  in 
pieces,  etc.).  And  the  higher  senses  also  often  present  an  exaggerated 
sensibility  or  great  bluntness,  and  actual  hallucinations.  All  these 
anomalous  sensations  urge  themselves  vividly  into  the  consciousness, 
awaken  and  maintain  an  idea  which  relates  to  the  disease  in  all  its  va- 
rious possible  forms  and  means  of  cure.  All  sensations  are  watched,  and 
seriously  commented  upon  and  analyzed  in  the  sense  of  the  ruling  gloomy 
and  anxious  frame  of  mind.  From  these  the  patient  concludes  that  he 
is  the  subject  of  very  serious  and  dangerous  diseases;  and  often  he  ex- 
presses his  fears  with  an  exaggeration  of  which  he  himself  is  half  aware, 
and  in  the  most  graphic  and  ludicrous  language.  The  patient  who  ex- 
hibits only  the  most  insignificant  symptoms  of  disease,  speaks  of  apo- 
plexy—asserts that  he  is  half  dead,  that  his  heart  is  dried  up  or  petrified, 
his  nerves  are  burning  coals,  his  blood  is  boiling  oil,  etc.  He  willingly 
allows  that  he  is  the  subject  of  serious  disorders,  or  of  entire  new  diseases 
which  have  never  before  existed,  because  the  gravity  and  danger  of  the 
disease  is  in  proportion  to  the  intensity  of  the  feeling  which  annoys  him. 
Whenever  the  morbid  sensations  change  their  situation  and  nature,  the 
ideas  regarding  the  seat  and  the  nature  of  the  disease  also  change,  and 


STATES    OF   MENTAL   DEPKESSION.  149 

the  patient  believes  himself  to  be  successively  attacked  with  all  the  dis- 
eases whose  pathology  he  knows.  So  much  do  these  ideas  constitute  a 
true  delirium,  so  false  and  purely  imaginary  are  they,  and  so  little  do  the 
sensations  Avhich  serve  as  their  basis  seem  to  be  connected  with  them, 
that  they  may  be  regarded  essentially  as  mere  attempts  at  explanation. 

We  therefore  find  here  exactly  the  same  origm— the  same  objective  ground- 
lessness and  subjective  foundation  of  the  delirious  conceptions  as  in  the  other 
forms  of  melancholia  and  more  advanced  insanity.  Take  from  the  hypochon- 
driac his  morbid  sensations,  and  he  will  no  longer  be  afflicted  with  his  imaginary 
diseases  ;  cause  the  feelings  which  agitate  and  torment  the  melancholiac  in  another 
way  to  disappear,  and  no  longer  will  he  believe  himself  to  be  pursued  by  his 
enemies,  etc.  In  melancholia  the  abnormal  feelings  which  precede  the  delirium 
are  as  r6al,  and.  at  least  at  the  commencement,  the  same  unstableness,  the  same 
abrupt  change  in  the  delirious  perceptions  prevails  as  in  hypochondria. 

§  114.  The  hypochondriac,  constantly  preoccupied  with  his  afflictions, 
seeks  by  every  possible  means  to  penetrate  them.  He  often  feels  his 
pulse,  examines  his  tongue  and  his  excretions,  and  frequently  discovers 
in  these  investigations  causes  for  fear  or  hope,  which  he  sometimes, 
though  the  details  may  be  very  disgusting,  takes  a  sort  of  pleasure  in 
communicating  to  everybody.  The  great  desire  to  be  cured  induces  him 
frequently  to  change  his  physician  and  his  treatment.  He  seeks  for  in- 
struction' by  reading  medical  books,  and  often  changes  his  opinion  re- 
garding the  nature  of  his  malady,  inasmuch  as  he  applies  to  his  own 
case  all  which  he  reads  or  hears  of.  The  mere  mention  of  a  disease  is 
sufficient  to  start  the  notion  that  he  himself  labors  under  it ;  and,  influ- 
enced by  this  idea,  he  now  discovers  in  the  corresponding  organs  phenom- 
ena which  he  had  never  before  experienced.' 

But  not  always  is  it  the  fear  simply  of  ordinary  bodily  diseases  which 
occupies  the  attention  of  the  hypochondriac,  and  is  the  object  of  his 
anxiety.  Frequently  the  mental"  element  in  his  malady  does  not  escape 
his  notice,  and  the  complete  change  of  his  personality,  the  possession  of 
morbid  sensations  and  ideas,  especially,  however,  a  certain  anomaly  (al- 
ready noticed  §  50),  particularly  in  the  mental  sphere,  in  the  sensorial 
sensations,  whereby  these,  although  perceived  as  formerly,  no  longer  pro- 
duce the  same  impressions,  frequently  form  the  great  subject  of  his  com- 
plaint. 

This  last  and  very  remarkable  state,  which  the  patients  themselves  have  much 
difficulty  in  describing,  which  we  also  have  ourselves  observed  in  several  cases  as 
the  predominant  and  most  lasting  symptom,  is  as  well  as  possible  described  m  the 
following  letter  of  one  of  Esquirol's  patients  : 

"  I  still  continue  to  suffer  constantly  ;  I  have  not  a  moment  of  comfort,  and 
no  human  sensations.  Surrounded  by  all  that  can  render  life  happy  and  agree- 
able, still  to  me  the  faculty  of  enjoyment  and  of  sensation  is  wanting— both  have 
become  physical  impossibilities.  In  everything,  even  in  the  most  tender  caresses 
of  my  children,  I  find  only  bitterness.  I  cover  them  with  kisses,  but  there  is 
something  between  their  lips  and  mine  ;  and  this  horrid  something  is  between  me 
and  all  the  enjoyments  of  life.  My  existence  is  incomplete.  The  functions  and 
acts  of  ordinary  life,  it  is  true,  still  remain  to  me  ;  but  in  every  one  of  them  there 
is  something  wanting— to  wit,  the  sensation  which  is  proper  to  them,  and  the 
pleasure  which  follows  them.  .  .  .  Each  of  my  senses,  each  part  of  my  iwoper 
self,  is  as  it  were  separated  from  me  and  can  no  longer  afford  me  any  sensation; 
this  impossibility  seems  to  depend  upon  avoid  wliichl/fieZ  in  the  front  of  my 
head,  and  to  he  due  to  the  diminution  of  the  sensibility  over  the  ivhole  surface  of 
my  body,  for  it  seems  to  me  that  I  never  actually  reach  the  objects  which  I  touch. 

'  One  cannot  help  being  struck  Mnth  the  remarkable  similarity  between  this 
process  and  the  production  of  hallucinations  in  general. 


150  STATES    OF    MENTAL    DEPRESSION. 

.  .  .  I  feel  ivell  enough  the  changes  of  temperature  on  viy  skin,  but  I  no  longer 
experience  the  internal  feeling  of  the  air  when  I  breathe  .  .  .  viy  eyes  see  and 
my  spirit  perceives,  but  the  sensation  of  that  tohich  I  see  is  completely  wanting," 
etc. 

The  psychical  changes,  too,  which  occur  in  the  sphere  of  the  will,  are, 
in  the  majority  of  instances,  very  striking.  The  patients  become  de- 
jected, thonghtfnl,  indecisive;  in  the  higher  grades  volition  is  altogether 
absent.  "I  wish  that  I  could  be  more  determined,  that  I  could  per- 
severe longer;  but  to  do  this  depends  no  longer  upon  myself.  I  feel  that 
if  I  could  will,  I  might  rescue  myself  from  this  desperate  situation,  but  I 
am  obliged  to  yield  to  my  painful  sensations.  I  feel  myself  incapable  of 
everything,  and  the  smallest  obstacle  appears  to  me  insurmountable," 
etc.  These  are  expressions  which  may  frequently  be  heard  in  the  higher 
degress  of  hypochondria,  as  well  as  in  all  other  forms  of  melancholia.' 
In  tlie  more  advanced  stage  of  tliis  disease,  the  intellect  also  suffers  not 
only  in  the  manner  of  which  we  have  been  speaking,  but  the  constant 
direction  of  the  thoughts  to  the  special  state,  and  the  means  which  might 
possibly  aid  him  impart  likewise  to  the  perception  a  certain  monotony, 
and  in  consequence  of  this  ruling  preoccupation  of  the  consciousness, 
everything  that  does  not  fall  within  this  circle  of  ideas  is  without  the 
slightest  interest,  of  perfect  indifference,  and  is  very  speedily  effaced 
from  the  memory.  Hence  it  is  that  such  patients  are  often  in  the  high- 
est degree  absent  and  forgetful.  They  are  very  loquacious  upon  the  one 
subject  of  their  affection,  but  are  little  inclined  to  speak  on  any  other 
theme;  and  those  are  never  severe  cases  of  hypochondria  where  the  pa- 
tient is  still  amiable  and  can  be  an  interesting  companion.  But  the  in- 
telligence and  acumen  which  the  patient  often  displays  in  fine  combina- 
tions upon  his  favorite  theme  may  still  remain  intact  as  also  in  regard 
to  objective  relations.  It  is  only  in  the  most  extreme  grades  of  hypo- 
chondria tliat  any  actual  diminution  in  the  intelligence  is  observed  in  a 
form  of  dull  and  morose  dementia  which  renders  the  sufferer  almost  in- 
capable of  any  intellectual  exertion. 

In  the  aggregate  of  these  mental  disorders  which  collectively  have  the  char- 
acter of  depression,  hypochondria  shows  itself  as  a  form  of  melancholia.  Although 
in  general,  on  account  of  the  peculiar  nature  of  these  delirious  conceptions,  and 
of  the  much  greater  command  which  the  patient  has  over  himself,  hypochondria 
may  be  regarded  as  to  a  certain  extent  specific,  yet  that  ruling  tendency  which 
the  patient  has  to  connect  and  to  compare  everything  with  himself,  the  limita- 
tion of  the  perception  to  the  special  7— this  morbid  egotism  is  an  essential 
characteristic  corresponding  to  the  concentration  in  self  of  the  melancholic  states 
in  general,  and  occasionally,  at  the  commencement  of  the  melancholic  perversion, 
it  is  more  by  chance  that  the  body  and  not  external  objects  becomes  the  object  of 
the  morbid  mode  of  thought.  The  higher  degrees  of  hypochondria,  too,  gradu- 
ally pass,  partly  through  increase  of  the  feeling  of  anxiety,  partly  through  the 
fixing  of  certain  attempts  at  explanation,  not  only  into  true  melancholia,  but  even 
comphcated  with  delusions  (ideas  of  being  surrounded  by  an  invisible  agency,  of 
being  the  victim  of  evil  machinations,  influenced  by  magnetism,  etc.).  That 
considerable  degree  of  self-control  also  which  hypochondriacs  still  possess,  often 
disappears  during  each  exacerbation.  Could  the  physicians  only  observe  these 
paroxysms  as  freely  as  they  can  at  any  time  in  severe  cases  in  asylums,  all  doubts 
concerning  the  mentally  morbid  nature  of  hypochondriasis  would  very  soon 
disappear. 

8  115.  Besides  these  mental  disorders  and  anomalies  of  the  sensations 


'  See  a  capital  example  of  absence  of  volition  in  hypochondria  by  Leuret, 

'  Fragmens,'  p.  383. 


STATES    OF    MENTAL    DEPRESSION.  151 

which  we  have  mentioned,  there  may  occur  in  almost  all  hypochondriacs 
innumerable  morbid  symptoms  in  all  the  various  organs,  and  that  old 
comparison  of  hypochondria  to  a  chronic  derangement  involving  the 
whole  nervous  system  with  fever,  as  the  most  general  acute  stage  of  the 
disease  (Hoffmann),  is  by  no  means  a  bad  one.  Thus,  for  instance,  very 
frequently  the  digestion  suffers,  the  tongue  is  loaded,  the  appetite  is 
immoderate  or  diminished,  the  bowels  are  constipated,  and  digestion  is 
accompanied  by  a  considerable  development  of  gas,  whereby  tension  is 
produced  in  the  hypochondriac  regions,  pushing  up  of  the  diaphragm  and 
causing  a  feeling  of  oppression.  Such  persons  are  frequently  afflicted 
with  haemorrhoids,  abdominal  pulsations,  palpitations  of  the  heart,  cere- 
bral congestion,  headaches,  disturbed  sleep ;  very  often  they  have  an 
abundant  mucous  expectoration  from  the  larynx  and  throat.  In  many 
cases  it  is  impossible  to  decide  whether  and  to  what  degree  these  very 
variable  symptoms  are  due  to  such  primary  disorders  of  the  viscera  under 
the  influence  of  which  the  hypocliondria  has  arisen,  or  how  far  they  are 
due  to  some  central  cause  in  the  nervous  system.  The  physician  has 
always  to  make  a  most  careful  examination  of  all  the  accessible  organs. 
Not  unfrequently  we  see,  during  the  course  of  the  mental  disease,  some 
visceral  affection  gradually  make  its  appearance  which,  in  its  obscure 
commencement,  may  be  etiologically  connected  to  the  hypochondria. 

It  is  evident  that  hypochondria  may  arise  in  two  different  ways.  In 
the  first  place,  as  a  secondary  cerebro-spinal  irritation,  in  consequence  of 
internal,  but  of  course  often  slight,  diseases  (of  the  intestinal  canal,  of 
the  liver,  of  the  genital  organs,  perhaps  also  of  the  kidneys),  which  give 
rise  more  to  a  feeling  of  general  discomfort  than  to  localized  pains.  These 
are  specially,  on  the  one  hand,  the  slighter  mechanical  obstructions  to  the 
passage  of  the  intestinal  contents,  flatulence,  and  in  particular  gastro- 
intestinal catarrhs,  which  very  often  give  rise  to  hypochondria  in  sensi- 
tive individuals,  and  that  too  often  of  a  most  aggravated  form  ;  and, 
on  the  other  hand,  affections  of  the  sexual  and  nervous  system  consequent 
on  onanism,  gonorrhoea,  and  venereal  excesses  ;  and,  finally,  all  dyscra- 
siae.  It  is  principally  to  these  three  series  of  affections  that  the  physician 
ought  to  direct  his  attention. 

In  the  second  place,  however,  hypochondria  may  undoubtedly  also 
arise  from  direct  moral  causes,  inasmuch  as  through  external  circum- 
stances the  ideas  may  be  so  constantly  directed  to  the  state  of  the  general 
health,  or  of  one  particular  organ,  as  to  induce  morbid  sensations.  This 
is  particularly  observed  in  those  who  read  medical  books,  who  are  fre- 
<^uently  in  the  company  of  hypochondriacs,  or  during  the  time  of  an  epi- 
demic, as  of  cholera,  etc.  Such  cases  are,  therefore,  less  severe  and  rare 
in  comparison  to  those  which  are  produced  by  indirect  moral  causes, 
such  as  depressing  emotions,  excessive  mental  exertion,  etc.  These 
generate  derangements  of  digestion,  of  the  circulation,  of  the  nutrition, 
etc.,  which  become  the  sources  of  the  feeling  of  illness. 

Hypochondriacal  states  are  sometimes  observed  in  the  years  of  child- 
hood, and  more  frequently  at  the  age  of  puberty.  They  are  extraordi- 
narily frequent  in  young  people,  and  more  rare  in  advanced  age.  They 
are  more  common  in  men  than  in  women  ;  however,  it  is  by  no  means 
rare  to  meet  with  most  characteristic  and  complete  cases  in  the  latter  sex. 
The  course  is  in  general  very  slow,  and  it  sometimes  presents  remissions. 
I  have  seen  some  cases  where  the  hypochondria  appeared  like  an  inter- 
mittent mania  at  almost  regular  periods,  with  intervals  of  several  years. 


152  STATES    OF    MENTAL    DEPRESSION. 

Another  time  I  observed  in  a  severe  case  (female  sex)  an  almost  complete 
remission  take  place  after  severe  spontaneous  diarrhcea,  combined  with 
lancinating  pains  in  the  vertebral  column. 

During  the  very  chronic  course  of  hypochondria,  the  nutrition  and 
appearance  of  the  patient  may  often  continue  good  for  a  long  time  ;  but 
when  an  organic  affection  of  some  of  the  viscera  becomes  developed,  the 
})atient  enters  into  a  stage  generally  prolonged  of  physical  languor,  with 
emaciation,  discoloration  of  the  skin,  great  weakness,  etc.,  wherewith 
occasionally  the  hypochondriacal  frame  of  mind  begins  to  disappear. 
Sometimes  also  symptoms  of  apoplexy,  of  paralysis,  develop  themselves  ; 
or  the  insanity  may  gradually  assume  another  form,  particularly  that  of 
partial  dementia  with  depression. 

Eecovery  is  not  unfrequently  obtained  by  moral  treatment,  but  alsa 
by  removal  of  all  physical  causes  ;  the  hypochondriacal  symptoms  have 
also  been  observed  to  disappear  with  the  accession  of  a  fit  of  gout  or  of 
intermittent  fever. 

Examj^les  of  simple  and  complicated  cases  of  hypochondria  of  various 
modes  of  origin,  appearance,  and  termination. 

Example  VII. — Simplest  case  of  hypochondria,  cured  hy  moral  treatment. — 
Mademoiselle  H — ,  set.  2\,  naturally  of  a  very  strong  constitution,  regular  in  her 
menstrual  periods,  though  the  flow  was  somewhat  scanty,  and  presenting  no 
other  deviation  from  perfect  health  than  a  continual  and  habitual  constipation, 
suddenly  lost  her  usual  cheerfulness  and  completely  secluded  herself.  In  vain, 
for  a  whole  year,  was  she  Implored  to  explain  this  sudden  change.  At  last  the 
patient  admitted  her  physician  to  her  confidence,  and  vowed  to  him  with  great 
bashfulness  the  cause  of  her  misery.  She  complained  that  she  felt  a  continued 
pain  in  her  right  hip,  a  feeling  of  uneasiness  there,  upon  which  all  her  thoughts 
were  concentrated.  Having  examined  this  region,  the  physician  was  unable  to 
discover  anything  that  would  account  for  this  sensation  of  which  the  patient 
complained;  when  she  all  at  once  burst  into  a  fit  of  weeping,  and  declared  that 
she  would  very  soon  die,  and  that  she  felt  convinced  her  bowels  were  about  to 
escape  from  her  half -open  abdominal  parietes.  The  physician  was  careful  not  to 
impugn  this  foolish  notion  altogether,  but  informed  his  patient  that  the  muscular 
covering  of  the  abdomen  was  sometimes  somewhat  weak  in  this  region,  as  in  her 
case,  and  that  to  remedy  this  weakness  it  was  only  necessary  to  wear  a  bandage 
round  the  part.  The  young  lady  adopted  his  advice,  and  with  the  use  of  the 
girdle  all  these  uneasy  feelings  completely  disappeared;  and,  what  is  also  worthy 
of  remark,  the  constipation  which  had  so  long  and  so  obstinately  persisted  also 
left  her.     ('  Bulletin  de  Therapeutique,'  1842,  p.  201.) 

Example  VIII. — Nervoufi  temperament;  hepatitis;  hypochondria;  death. — Mr. 
M —  was  of  a  nervous  excitable  temperament;  good-natured,  sprightly,  and  en- 
dowed Avith  a  vivid  imagination,  he  devoted  his  utmost  energies  to  his  business. 
He  married  at  the  age  of  thirty-one.  Up  to  this  time,  everything  had  gone  on 
prosperously  and  happily  with  him.  Though  he  endured  suffering  with  the 
utmost  courage  and  magnanimity,  yet  the  smallest  trifles  annoyed  him,  and  he 
could  not  rid  his  thoughts  of  them. 

One  year  after  marriage,  he  was  attacked  with  a  very  severe  and  acute  hepatitis. 
The  liver  projected  four  fingers'  breadth  below  the  false  ribs.  (Eighteen  leeches 
ad  anum.)  The  inflammation  subsided,  but  with  the  return  of  the  liver  to  its 
natural  size,  the  irritability  of  the  patient  increased;  a  mere  nothing  made  him 
impatient,  and  everything  was  a  perpetual  source  of  pain  and  annoyance  to  him. 
The  most  gloomy  apprehensions  as  to  the  nature  of  his  liver  complaint  were 
awakened  in  him.  He  began  to  think  of  obstruction  and  cancer,  and  looked  for- 
ward to  a  future  of  pain.  In  spite  of  this,  his  cure  was  complete;  only  there 
remained  a  greatly  increased  nervous  sensibility,  a  tendency  to  exaggerate 
everything,  and  his  temper  became  extremely  variable. 

At  one  time  he  was  gay  and  cheerful,  as  formerly ;  and  at  another,  choleric 
and  fiery,  without  any  perceptible  cause.  Changes  of  temperature  had  a  marked 
influence  on  him.  In  his  iiioments  of  bad  humor,  he  suffered  pain  in  all  parts  of 
his  body,  according  as  his  attention  was  directed  to  them.  But  he  complained 
almost  constantly  of  a  pain  in  his  right  hypochondrium,  which  he  ascribed  to 


STATES    OF    MENTAL    DEPRESSION.  153 

his  liver.  His  digestion  was  often  faulty,  and  he  had  distinct  epigastric  pulsa- 
tion. He  now  believed  himself  attacked  by  a  fatal  gastritis.  A  tickling  in  the 
throat,  with  a  slight  dry  cough,  or  the  expectoration  of  some  mucus,  then 
awakened  in  him  the  idea  that  he  was  consumptive.  He  took  to  reading 
medical  books,  and  imagined  himself  to  be  the  subject  of  every  disease  he  read 
of.  At  the  same  time,  he  occasionally  came  to  the  conviction  that  all  his  sus- 
picions were  groundless,  and  he  often  had  entire  months  of  resj)ite  from  his 
affliciion. 

In  the  year  1831,  the  patient  was  attacked  by  a  very  serious  fcA^er  which 
affected  the  mucous  tissues,  accompanied  by  great  nervous  irritation  and  violent 
pains  in  the  right  shoulder.  No  sooner  was  he  cured  of  this,  than  he  complained 
of  greater  pains,  which  recurred  more  frequently  than  ever.  For  this,  a  course 
of  mineral  waters  and  travelling  was  prescribed.  But  any  amelioration  was  con- 
stantly broken  in  upon  by  new  suiferings  and  new  fears,  which  very  soon 
reduced  him  to  a  perfect  skeleton. 

Some  time  after  this,  pains  in  the  lumbar  regions,  a  burning  sensation  in  the 
urethra  and  bladder,  suggested  to  him  the  idea  of  catarrh  of  the  bladder,  or  of 
stone;  and,  in  fact,  he  did  pass  some  gravelly  particles.  From  this  time  forward, 
his  phantasy  left  him  no  longer  at  rest.  Incessantly  occupied  with  his  sufferings, 
which  were  much  exaggerated  by  the  attention  paid  them,  and  by  the  careful 
manner  in  which  they  were  analyzed,  his  temper  became  more  and  more  irrita- 
ble, and  he  scarcely  ever  had  one  moment's  peace.  Sometimes  he  gave  himself  up 
to  a  sort  of  rage  and  despair,  but  more  often  he  sank  into  a  state  of  gloomy 
depression,  in  which  he  fancied  that  his  end  was  at  hand,  and  that  he  was  to  be 
cut  off  by  one  of  the  five  maladies  by  which  he  was  in  turn  afflicted.  Thus  he 
became,  latterly,  in  the  highest  degree  eccentric  and  phantastic.  Nothing  pleased 
him,  everything  was  hateful  to  him.  The  most  assiduous  attentions  were 
ungratefully  received  by  him,  and  he  would  weep  over  the  misfortune  that  placed 
him  in  such  circumstances.  Then  he  would  ask  his  wife's  pardon  for  all  his 
injustice  to  her,  and  again  would  take  it  into  his  head  that  she  no  longer  loved 
him;  and  this  thought  became  a  new  source  of  disti'ess. 

He  now  retired  from  business.  By  constantly  pondering  over  his  afflictions, 
he  increased  still  more  the  nervous  irritability  which  gave  rise  to  them.  He  con- 
sulted all  the  physicians  that  were  suggested  to  him,  and  the  desire  to  become 
well  urged  him  to  follow  their  prescriptions  most  eagerly.  He  soon  discovered 
the  inefficiency  of  their  remedies,  which  only  inflicted  upon  him  renewed  pain. 
The  disappointment  of  his  hopes  tended  to  incite  his  delusive  imagination,  to 
increase  his  nervous  excitement  and  undermine  his  strength.  In  1834,  he  was 
again  attacked  with  a  fever,  which  attached  itself  principally  to  the  mucous  tis- 
sues, during  which  his  temper  was  almost  unbearable.  He,  however,  rallied,  but 
without  any  alleviation  of  his  nervous  sufferings.  Perpetually  tormented  with 
his  peculiar  phantasies,  he  tot)k  it  seriously  into  his  head  that  he  was  a  martyr  to 
stone  in  the  bladder,  and  nothing  would  persuade  him  to  the  contrary.  He  per- 
sisted in  this  belief,  and  set  off  to  visit  a  celebrated  lithotritist  in  Paris.  The 
examinations  which  he  there  underwent  so  irritated  the  urethral  canal  and  the 
bladder,  that  at  the  end  of  a  few  days  the  patient  died.  No  autopsy  was  made. 
(Brachet,  '  De  I'Hypochondrie,'  Paris,  1844,  p.  29.) 

Example  IX. — Weakejied  constitution  and  melancliolia  from  vioral  causes; 

recovery  through  satisfaction  of  a  passion. — Madame ,  get.  26,  of  great  mental 

and  physical  sensibility,  was  the  mother  of  three  children.  Her  health  was  good, 
until  the  persevering  attentions  of  a  visiting  acquaintance  completely  gained  her 
affections.  Filled  with  ideas  of  her  duty,  she  resisted  the  seducing  influence,  and 
kept  the  secret  of  a  violent  passion  buried  in  her  heart.  This  constraint  gradually 
affected  her  health:  she  began  to  suffer  from  palpitation,  sensation  of  fulness  at 
the  chest,  and  indescribable  morbid  symptoms.  The  appetite  failed,  the  gastric 
region  felt  painful,  and  stitches  were  felt  in  the  side.  To  these  actual  sensations 
were  associated  the  most  peculiar  and  sad  ideas  concerning  her  health.  She 
believed  sometimes  that  she  suffered  from  aneurism,  sometimes  from  cancer  of 
the  stomach,  sometimes  and  most  frequently  from  consumption.  Indeed,  a  feel- 
ing of  tenseness,  cough  and  abundant  expectoration,  feverishness  and  nocturnal 
perspirations,  had  established  themselves.  The  doctor  suspected  phthisis,  and 
sent  the  patient  to  the  South  of  Europe.  On  her  journey  she  consulted  me.  I 
found  her  mental  condition  much  affected,  and  her  imagination  seriously  involved. 
Her  sufferings  were,  according  to  her  own  testimony,  actually  fearful;  sharp,  red- 
hot  irons  were  forced  through  her  flesh,  the  fliires  of  which  wei-e  torn  as  if  by 
pincers.     She  did  not,  hower,  complain  much  of  the  pulmonary  organs.     After 


154  STATES    OF    MENTAL    DEPRESSION. 

six  months'  residence  in  the  South  of  France,  she  was  neither  bodily  nor  mentally 
improved.  The  pulmonary  affection  seemed  not  to  have  extended,  but  her 
imagination  was  far  more  disordered ;  she  exhibited  a  greater  tendency  to  view 
every  tiling  in  its  worst  light;  and  on  her  return  to  Paris  her  state  became  still 
worse.  There  she  again  saw  the  object  of  her  passion,  succumbed,  abandoned 
her  husband  and  family,  and  fled  with  her  seducer. 

Six  months  afterwards  I  saw  her  again.  I  could  scarely  recognize  her. 
Beauty,  freshness,  and  fulness  were  in  the  place  of  a  condition  bordering  on 
marasmus.  There  was  no  longer  cough,  expectoration,  palpitation,  gastric  affec- 
tion, pain,  or  any  disease.  The  gratification  of  her  passion  had  re-established 
her  health  and  dissipated  the  dark  ideas  of  hypochondriasis.  (Brachet,  '  De 
I'Hypochondrie,'  p.  69.) 

•  Example  X. — Hypochondriasis  produced  by  a  moral  cause  and  nourished  by 

superstition;  recovery  by  moral  means. — A.  M ,  an  active  and  laborious  but 

very  simple  woman,  injured  her  arm  through  a  fall.  A  bone  setter  who  was  con- 
sulted declared  "the  veins  of  the  arm  were  too  much  disordered  for  him  to  cure 
her  completely."  She  now  sought  the  aid  of  a  physician;  but  as  the  arm  still  re- 
mained uncured,  she  came  to  the  conclusion  that  a  vein  in  her  arm  might  have 
been  broken,  and  that,  owing  to  want  of  the  vein,  she  would  never  again  be  able 
to  veork  with  it. 

This  sad  idea  constantly  pursued  her;  she,  in  the  most  unhappy  frame  of  mind, 
complained  to  her  friends  of  her  fate.  Some  one  advised  her  to  lay  the  leg  of  a 
frog  on  the  spot  where  the  vein  was  injured,  and  throw  it  afterwards  into  the 
river.  Wlien  she  had  done  this,  she  felt  from  that  moment  the  roar  of  the  water 
in  her  head.  Her  sad  and  melancholy  disposition  had  now  reached  the  highest 
degree;  she  believed  that  all  her  sufferings  were  a  punishment  from  God,  because 
she  had  not  prayed  sufiiciently  when  she  was  a  child,  and  reflected  on  her  father  for 
not  having  more  strictly  enforced  this  duty.  In  order,  however,  to  make  amends 
for  her  fault,  she  prayed  day  and  night. 

Her  son,  who  was  twenty -three  years  of  age,  a  reader  of  religious  books  and  of 
irreproachable  character,  nursed  and  humored  his  mother  with  such  diligence, 
that  his  friends,  anxious  regarding  the  state  of  his  health,  sought  to  divert  him 
by  bringing  him  into  lively  society.  He  was  very  bashful;  and  a  lively  girl  hav- 
ing grasped  his  arm  with  some  force  in  order  to  make  him  sit  down,  he  felt  the 
arm  painful.  When  he  got  home,  the  mother's  sorrowful  complaints  led  him  to 
think  that  the  same  thing  had  happened  to  himself,  and  that  he  also  had  had  a 
vein  broken.  Next  morning  the  pain  was  actually  much  more  severe,  and  the 
young  man  believed  that  he  was  less  able  to  use  his  arm.  He  became  every  day 
worse;  he  ceased  to  work,  and  felt  assured  that  a  vein  was  wanting;  and  by-and- 
by  it  seemed  to  him  impossible  to  use  the  arm  in  the  least.  The  whole  employ- 
ment of  mother  and  son  consisted  now  in  praying. 

By  constantly  brooding  over  his  state,  the  latter  commenced  to  think  that, 
owing  to  the  connection  between  the  veins  of  both  arms,  the  otlier  would  also 
suffer — in  a  moment  he  became  unable  to  move  tho  other  arm,  and  in  the  course 
of  a  year  he  fell  into  such  a  state  of  apathy  that  he  had  to  be  dressed  and 
undressed,  as  well  as  fed.  In  the  case  of  the  mother  also,  the  melancholia  and 
the  religious  ideas  inci-eased;  she  thought,  as  often  as  she  lighted  the  fire,  that 
she  lighted  the  flames  of  hell,  etc.,  and  her  misery  became  so  great  that  she 
attempted  to  commit  suicide.  The  son  could  only  be  weaned  from  the  idea  of 
starving  himself  through  the  exhortations  of  a  clergyman. 

I  found  both  individuals  engaged  in  their  only  employment,  viz.,  praying. 
The  young  man  held  both  arms  straight  downwards,  with  hands  and  fingers  ex- 
tended. He  complained  that  he  could  not  give  me  his  hand,  because  there  was  a 
vein  wanting  in  his  arm.  He  came  nearer  to  me,  and,  after  a  minute  investiga- 
tion, I  said  to  him  that  of  course  a  vein  was  wanting,  giving  him  at  the  same 
time  a  positive  assurance  that  I  would  help  him. 

I  now  ran  my  fingers  up  and  down  the  arm  in  the  direction  indicated,  and 
stopping  suddenly  at  the  long  nail  of  the  thumb,  hurriedly  cut  off  the  end  of  the 
nail,  together  with  a  piece  of  the  flesh,  so  that  it  bled.  I  tlien  rubbed  the  arm 
strongly  with  both  hands,  and  exclaimed  with  a  loud  voice,  "With  God's  help  it 
has  succeeded — the  vein  is  now  there!"  In  order  to  convince  him  that  the  vein 
really  existed,  he  was  shown  the  flowing  blood,  and  he  was  immediately  compelled 
to  make  certain  movements. 

But,  as  the  mother  remonstrated  that  the  recovery  of  her  son  was  not  yet 
possible,  because  he  still  bore  the  mark  of  daiiniation  (namely,  black  dirt  upon  the 
<;hest),  this  was  imine<liately  rubbed  off  and  liis  skin  cleansed.     The  son  now,  after 


STATES    OF    MENTAL    DEPRESSION.  155 

some  religious  exhortation,  shook  hands  with  the  bystanders,  put  off  and  on  his 
clothes,  and  on  the  following  day  commenced  to  work  by  thrashing  some  corn. 
The  mother,  too,  convinced  of  the  actual  recovery  of  her  son,  again  resumed  her 
diligent  habits,  and  both  are  now  bodily  and  mentally  well.  (Berlyn,  in  Nasse, 
'Zeitschr.  f.  Psych.  Aerzte,'  ii.,  1819.) 

Example  XI. — Heart  disease,  hypochondriasis,  several  feigned  operations 
xvithout  decided  result;  feverish  state;  recovery,  relapse.— Lucy  M— ,  a3t.  50,  with 
no  hereditary  disposition  to  insanity,  was  chlorotic  at  14,  married  at  22  (two 
abortions  and  eight  ordinary  births).  During  her  second  pregnancy,  she  was 
seized  with  violent  headache,  with  vertigo  and  delirium,  which  ceased  at  her 
confinement.  For  the  last  twenty  months  she  has  not  menstruated.  In  Decem- 
ber, 1839,  she  was  seized  with  a  general  feeling  of  ill-being,  with  pains  in  the 
gastric  region,  beatings  in  the  whole  body,  and  nervous  attacks.  During  her 
residence  in  the  hospital,  the  patient  suddenly  remembered  of  having  drunk  out 
of  a  well  in  which  there  were  three  spiders.  From  that  moment  she  felt  convinced 
that  she  had  swallowed  them,  and  fell  into  the  most  violent  agitation,  owing 
to  which  she  was  on  the  11th  February,  1840,  removed  to  the  lunatic  asylum  at 
Tours. 

She  complained  of  formication  and  smarting  over  all  her  body;  stitches  and 
beating  at  the  breast,  stomach,  abdomen,  and  limbs;  ringing  of  the  ears,  sleepless- 
ness, vertigo,  and  peculiar  dreams.  The  course  of  her  thoughts  was  regular,  and 
her  answers  correct;  but  so  soon  as  she  referred  to  the  subject  of  her  delirium, 
she  became  agitated,  and  spoke  not  only  of  spiders  which  inwardly  pained  her, 
but  of  demons,  serpents,  and  beasts  of  all  descriptions  which  gnawed  at  her. 
There  was  slight  hypertrophy  of  the  heart,  and  a  bruit  with  the  first  sound;  the 
pulse  was  hard  (calming  remedies,  digitahs).  Constant  restlessness,  and  doubts 
concerning  the  possibility  of  recovery  (gamboge).  In  the  stools  excited  by  this 
remedy,  three  spiders  were  secretly  placed,  which  the  patient  was  allowed  to  dis- 
cover; but  she  at  once  replied,  "These  are  the  old  ones;  they  have  left  their  young 
behind— I  feel  them  in  my  bowels."  The  same  contrivance  was  twice  repeated; 
but  the  patient  felt  certain  that  the  spiders  multiplied  tremendously,  and  were 
now  in  her  body  from  head  to  foot.  Every  attempt  to  convince  her  of  the  error 
of  her  idea  was  met  with  threats  and  abuse. 

It  was  now  proposed  to  her  to  have  an  operation  performed,  through  which 
all  the  spiders  must  certainly  be  removed.  She  received  the  proposal  with  joy, 
longed  for  the  hour  of  the  operation,  and  spoke  of  her  recovery  with  hope  and 
confidence.  The  operation  was  performed  with  great  solemnity,  in  presence  of 
several  physicians,  in  order  to  make  an  impression  on  the  imagination  of  the 
patient.  It  consisted  in  a  slight  incision  of  the  skin  of  the  back,  and  several 
spiders  which  were  held  in  readiness  were  allowed  to  run  about  the  bed,  she 
believing  that  they  were  taken  from  her  body.  She  said  that  she  felt  their 
removal  distinctly,  and  rejoiced  at  the  result.  These  small  incisions  were  fre- 
quently repeated  in  all  parts  of  her  body.  At  this  time  she  took  intermittent 
fever  (quinine,  antispasmodics),  was  always  excited,  felt  insupportable  pain  over 
the  whole  body,  and  constantly  begged  for  new  operations.  Once  she  attempted 
to  tlirow  herself  from  the  window,  but  without  doing  herself  any  injury;  at 
another  time  she  attempted  to  strangle  herself.  Finally,  it  was  declared  to  her 
that  now  there  were  no  more  spiders  in  her  body;  and  to  convince  her  of  this, 
two  new  incisions  were  made,  the  oesophageal  sound  used,  and  purgatives 
administered.  On  September  9th,  she  still  attributed  certain  physiological 
phenomena  to  the  presence  of  the  spiders— the  rising  and  falling  of  the  larynx, 
the  arterial  pulse,  etc.  She  was,  however,  soon  convinced  that  these  appear- 
ances were  present  in  all  men.  There  now  appeared  a  feverish  state,  with  bead- 
ache  and  ringing  of  the  ears;  and  on  the  18th  September,  all  the  symptoms  had 
disappeared. 

The  patient  now  became  completely  quiet,  happy,  and  thankful,  and  was 
employed  in  the  kitchen.  The  news  of  the  death  of  her  husband,  which  was 
rashly  told  her,  vexed  her  very  much,  but  in  no  way  disturbed  her  mental  health. 
During  the  next  winter,  however,  which  was  very  severe,  living  in  the  most 
indigent  circumstances,  and  struggling  against  cold  and  hunger,  she  suffered  a 
relapse,  accompanied  with  violent  palpitation,  agitation,  mania,  and  attempt  at 
suicide.  The  patient  was  no  longer  treated  according  to  her  false  ideas,  but 
gradually  recovered  under  simple  nutrient  treatment,  affusions,  baths,  narcotic 
and  aperient  medicines.     (Charcellay,  '  Annales  Med.  Psychol.,'  ii.,  1843,  p.  485.) 


156  STATES    OF    MENTAL    DEPRESSION. 


Sectioj^  II. — MelmichoUa  in  a  more  Limited  Sense. 

§  116.  Anomalies  of  self -consciousness,  of  the  desires,  and  the  will. 
— In  many  cases,  after  a  period  of  longer  or  shorter  duration,  a  state  of 
vague  mental  and  bodily  discomfort,  often  with  hypochondriacal  perver- 
sion, depression,  and  restlessness,  sometimes  with  the  dread  of  becoming 
insane,  passes  off,  a  state  of  mental  pain  becomes  always  more  dominant 
and  persistent,  but  is  increased  by  every  external  mental  impression.  This 
is  the  essential  mental  disorder  in  melancholia,  and,  so  far  as  the  patient 
himself  is  concerned,  the  mental  pain  consists  in  a  profound  feeling  of 
ill-being,  of  inability  to  do  anything,  of  suppression  of  the  physical 
powers,  of  depression  and  sadness,  and  of  total  abasement  of  self -con- 
sciousness. So  soon  as  this  condition  of  the  sensorium  attains  a  certain 
stage,  the  most  important  and  wide-spread  consequences,  as  regards  the 
demeanor  of  the  patient,  result. 

The  disposition  assumes  an  entirely  negative  character  (that  of  abhor- 
rence or  repulsion).  All  impressions,  even  the  slightest  and  formerly 
most  agreeable,  excite  pain.  The  patient  can  no  longer  rejoice  in  any- 
thing, not  even  the  most  pleasing.  Everything  affects  him  uncomfort- 
ably, and  in  all  that  happens  around  him  he  finds  new  sources  of  pain. 
Everything  has  become  repulsive  to  him;  he  has  become  irritable  and 
angry.  Every  trifle  puts  him  out  of  temper.  The  result  is,  either  per- 
petual expressions  of  discontent,  or — and  this  is  more  common — he 
endeavors  to  escape  from  all  outward  mental  impressions,  by  withdrawing 
himself  from  the  society  of  men,  and,  completely  idle  and  unemployed, 
seeking  solitude.  This  general  feeling  of  aversion  and  indifference  is 
often  expressed  by  a  dislike  towards  those  by  whom  he  is  surrounded,  his 
family,  friends,  and  relatives,  which  often  merges  into  absolute  hatred — 
by  a  complete  and  unhappy  change  in  his  character. 

We  may  sometimes  observe  in  individuals  apparently  healthy  (partic- 
ularly among  females)  a  similar  though  much  more  chronic  state  of 
habitual  perversion  of  sentiment,  accompanied  by  a  capricious  and  morose 
disposition,  with  a  tendency  to  contradiction  and  ill-nature.  Neverthe- 
less, it  is  very  rarely  that  this  is  regarded  as  a  morbid  state,  even  although 
it  differs  widely  from  similar  evil  dispositions  which  we  see  sometimes 
displayed  in  those  who  are  perfectly  healthy, — through  its  frequent  origin 
from  palpable  diseases,  through  its  frequent  remissions,  which  are  explic- 
able by  no  well-grounded  mental  motive,  and  through  the  fact  that  at 
times  the  patient  feels  himself  constrained  to  yield  to  the  evil  disposition 
in  direct  opposition  to  the  dictates  of  his  conscience  and  his  will,  and 
although  he  is  perfectly  aware  that  such  conduct  is  most  unwarrantable. 

In  simple  melancholia  we  frequently  find  a  condition  of  the  sensorium 
precisely  analogous  to  that  which  we  have  described  under  the  head  of 
Hypochondria,  in  which  the  objects  of  the  outer  world,  although  they 
come  into  consciousness  through  the  medium  of  the  senses,  and  are  in- 
deed properly  understood  and  recognized,  still  they  produce  an  impression 
utterly  different  from  what  they  were  wont  to  do,  of  which  the  intelligent 
and  educated  sufferers  can  alone  give  a  true  description.  ''It  appears  to 
me,"  says  such  a  melancholic,  "that  everything  around  me  is  precisely 
as  it  used  to  be,  although  there  must  have  been  changes.  Everything 
around  me  wears  the  old  aspect,  everything  appears  as  it  was,  and  yet 
there  must  have  been  great  cluinges.''etc.     This   confounding   by  the 


STATES    OF    MENTAL    DEPRESSION.  157 

patient  of  the  subjective  cliango  of  exterior  things,  and  then  objective 
change,  is  the  commencement  of  tliat  dreamy  state,  in  which,  when  it 
has  attained  to  a  tolerably  high  degree,  it  appears  to  the  patient  as  if  the 
real  world  had  actually  and  completely  vanished, — that  it  has  sunk,  dis- 
appeared, or  is  dead,  and  all  that  now  remains  to  hini  is  an  imaginary 
Avorld,  in  tlie  midst  of  which  he  is  perpetually  tormented  by  finding  that 
he  has  still  to  live. 

At  'he  jeginning  of  this  state  the  patient  is  perfectly  cognizant  of  the 
change  vhich  has  taken  place  in  his  moral  nature,  in  all  his  feelings  and 
affections.  Sometimes  he  seeks  to  hide  it,  and  the  inquiries  concerning 
the  cause  of  his  peculiar  behavior  weary  and  annoy  him.  He  feels  that  his 
former  enjoyment  in  everything  that  was  honorable  and  estimable  is  fast 
passing  into  indifference  and  actual  repugnance.  He  even  complains 
himself  that  his  sensations  are  no  longer  natural,  that  they  are  perverted, 
and  vhen  his  evil  genius  constrains  him  to  regard  the  worst  side  of  the 
world,  a  new  source  of  pain  and  sorrow  is  presented  to  him,  viz.,  that  he 
can  rejoice  about  nothing,  and  must  oppose  everything.  The  unwonted 
impressions  from  the  outer  world  excite  his  astonishment,  grief,  and 
fear.  He  feels  himself  excluded  from  his  former  intercourse  with  society; 
and  this  feeling  of  isolation,  this  exceptional  position  in  which  he  finds 
himself,  favors,  on  the  one  hand,  the  limitation  of  all  ideas  concerning 
the  relation  in  which  he  stands  to  the  world,  and  the  relation  of  external 
objects  to  himself.  On  the  other  hand,  there  proceeds  from  this  feeling 
of  isolation,  distrust,  anxiety,  and  fear  of  all  possible  evils — sometimes  a 
feeling  of  hatred  and  revenge  towards  the  world,  but  more  often  a  power- 
less, helpless  withdrawal  from  society  and  concentration  in  himself. 

That  which  weighs  most  heavily  upon  the  mind  of  the  patient  at  the 
commencement  of  his  trouble,  is  that  feeling  of  change  which  has  taken 
place  in  his  own  personality,  that  vagueness  and  obscurity  arising  from 
this  undefined  feeling  of  annoyance.  Yet  at  this  stage  he  is  sometimes 
perfectly  aware  that  his  fears  are  absurd,  and  that  those  uneasy  thoughts 
which  force  themselves  upon  him  are  utterly  false;  and  he  is  even  con- 
scious of  his  own  actual  state.  But  then,  he  perceives  that  it  is  impossi- 
ble for  him  to  feel,  to  think,  to  act  otherwise  than  he  does, — that  he 
cannot  resist,  and  how  useless  every  effort  at  resistance  is;  then  he 
receives  from  his  overcoming  of  the  Ego  (§  22)  the  idea  of  being  ruled,  of 
being  irresistibly  abandoned  to  some  foreign  influence,  to  which,  after- 
wards, ideas  of  being  governed  by  evil  powers,  of  secret  direction  of  the 
thoughts,  of  demoniacal  possession,  etc.,  correspond. 

The  limitation  of  the  will,  which  is  one  of  the  fundamental  disorders 
of  melancholia,  is  manifested  by  inactivity,  cessation  of  all  employment, 
constant  doubt  and  irresolution,  incapacity  of  decision,  and  abscence  of 
will.  In  the  higher  degrees,  it  shows  itself  in  actual  torpidity  and  dul- 
ness  of  feeling,  inasmuch  as  impressions  are  no  longer  followed  by  a 
reaction  of  the  will;  in  the  more  moderate  degrees,  as  slowness,  monotony, 
hesitation  in  movement  and  action,  feeling  of  incapacity  for  the  slightest 
mental  exertion,  lying  in  bed,  etc. 

Frequently  there  are  sensations  of  intense  anxiety,  which  often  appear 
to  spring  from  the  epigastric  and  cardiac  regions,  and  to  mount  upwards. 
"  Here,"  say  many  of  these  patients,  pointing  totheepigastiium — ''here 
it  remains  like  a  stone:  would  that  I  could  get  rid  of  it!"  These  feelings 
of  anxiety  sometimes  increase  to  such  an  extent  as  to  be  almost  unbear- 
able; thus  driving  the  patient  into  a  state  of  despair,  whicli  generally 
passes  into  an  attack  of  mania.     Moreover,  these  states  manifest  them- 


158  STATES    OF    MENTAL    DEPKESSION. 

selves  externally  in  many  various  forms,  accordino-  to  the  former  disposi- 
tion of  the  patient,  the  moral  causes,  and  accomiuiaying  physical  anoma- 
lies, etc. ;  at  times,  with  the  outward  signs  of  grief  and  care,  or  as  silent 
melancholy,  as  self-concentration,  or  a  dull,  passionless,  reserved  bearing; 
sometimes  as  loud  self-accusation,  with  weeping,  wringing  of  the  hands, 
and  great  restlessness;  sometimes  as  morbid  peculiarity  and  intractable 
obstinacy;  or,  finally,  as  a  tendency  to  lay  violent  hands  on  self. 

There  are  some  melancholies  who  are  always  discontented,  and  whom 
nothing  pleases;  others  to  whom  everything  is  alike  indilferent,  because 
their  attention  is  completely  absorbed  in  the  contemplation  of  their  own 
misfortune;  and  others  who  maintain  that  for  them  ''everything  is  too 
good,  and  they  cannot  understand  how  it  is  that  people  do  not  despise 
such  miserable  creatures  as  they  are." 

All  these  varieties  in  the  disposition  of  melancholies  are  at  the  com- 
mencement generally  unaccountable,  and  do  not  depend  on  certain  defi- 
nite delirious  conceptions;  tlierefore  it  is  that  the  patient  himself  is  also, 
at  this  stage,  perfectly  incapable  of  giving  any  statement  which  might 
account  for  his  present  condition.  ''I  am  afraid,"  says  such  a  patient; 
and  if  asked  Avhy,  he  can  only  reply,  *'  I  don't  know,  but  I  am  afraid  " 
(Esquirol).  Hence,  we  are  constrained  to  come  to  the  conclusion — which 
indeed,  observation  has  led  us  to,  and  serves  only  every  day  to  confirm — 
that  exhortations,  solicitude,  and  argument  have  not  the  slightest  effect 
iipon  this  state  of  depression,  engendered  by  some  cerebral  lesion;  and  that 
the  ideas  which  conduce  to  the  development  of  this  state  must  have  an 
internal,  subjective  origin,  and  therefore  a  character  of  irrefutability,  so 
that  they  render  the  patient  wholly  impervious  to  anything  like  argu- 
ment, and  at  best  only  permit  him  to  exchange  one  mournful  train  of 
ideas  for  another. 

§  117.  Anomalies  of  the  mtellect. — The  painful  concentration  of  the 
mind  represses  the  vivacity  and  the  natural  course  of  the  thoughts.  A 
few  ideas  occupy  the  mind  of  the  patient,  and  all  that  he  gives  utterance 
to  is  a  few  monotonous  complaints  regarding  himself,  and  of  the  sad  change 
which  has  come  over  him.  Or,  he  continually  reverts  to  certain  events 
which  happened  about  the  commencement  of  his  illness,  etc.  All  desire 
for  intellectual  intercourse  with  his  friends  is  generally  very  much  dimin- 
ished. The  patient  often  sits  perfectly  mute,  or  at  best  speaks  timidly, 
with  hesitation,  in  a  low  tone,  frequently  interrupting  himself.  One 
melancholic  who  was  under  my  charge  preserved  an  inviolable  silence  for 
several  years,  and  it  was  only  from  his  physiognomy  that  we  learned  his 
ruling  disposition,  for  it  expressed  most  unequivocally  intense  anxiety  and 
sadness,  while  at  times  he  would  weep  and  wring  his  hands.  In  other 
cases  the  patient  bewails  himself,  heaves  deep  sighs,  and  is  engaged  in 
prayers  and  supplications,  but  always  on  the  same  subject;  yet,  in  spite 
of  the  extraordinary  monotony  of  his  intellectual  life,  he  never  becomes 
a  prey  to  ennui. 

Together  with  these  formal  disorders,  there  now  appear  false  ideas 
and  judgments,  corresponding  to  the  actual  disposition  of  the  patient. 
Thus,  for  example,  he  feels  that  he  is  in  a  state  of  anxiety  of  mind  exactly 
similar  to  that  which  a  criminal  is  likely  to  experience  after  the  perpe- 
tration of  some  misdeed,  and  so  he  believes  that  he,  too,  has  committed 
some  crime;  and  from  this  predominating  idea  he  cannot  rid  himself. 
But  as  in  the  review  of  his  life  he  is  unable  to  recall  what  this  crime  is, 
he  fixes  upon  some  insignificant  event,  when  he  has  committed  some  tri- 
vial fault,  some  petty  carelessness  (or  perhaps  he  may  not  even  be  guilty 


STATES    OF    MENTAL   DEPRESSION.  ]  59' 

of  that),  and  this  unfortunate  occurrence  beconies  the  subject  of  bis  de- 
lirium. In  it  he  discovers  the  cause  of  bis  present  misfortunes,  and  his 
fears  for  the  future.  Sometimes  he  feels  himself  the  prey  of  some  unde- 
fined torment,  and  imagines  himself  encompassed  with  enemies.  Soon 
he  actually  considers  himself  persecuted,  surrounded  by  foes,  the  subject 
of  mysterious  plots,  and  watched  by  spies;  and  as  he  connects  everything 
with  himself,  the  most  insignificant  matter  tends  to  nourish  his  delirium. 

Again,  the  patient  who  formerly  cherished  religious  ideas  feels  how 
profoundly  he  has  changed  in  regard  to  this  train  of  thought;  how  this 
state  of  anxiety  and  uneasiness  renders  him  totally  incapable  of  reflection; 
how,  consequently,  he  is  unable  any  longer  to  pray,  or  at  his  devotions 
he  is  assailed  by  unhappy  negative  ideas.  He  feels  that  the  church  and 
all  other  external  objects  give  rise  in  him  merely  to  painful  impressions. 
Thus  he  seems,  in  his  exceptionable  position,  like  a  castaway  whom  God 
has  given  up  and  abandoned  to  the  devil  and  to  eternal  damnation. 
Soon  he  comes  actually  to  believe  that  he  has  indeed  committed  grave 
faults,  innumerable  sins,  and  that  he  has  entirely  neglected  his  duties, 
etc.  Hence  we  see  that  it  often  depends  upon  chance,  upon  which  par- 
ticular thoughts  or  ideas  the  patient  attaches  so  much  importance  that 
they  recur  to  him  as  fixed  or  partially  fixed  delusions. 

All  these  melancholic  insane  ideas  have  one  essential  character,  that 
of  passive  suffering,  of  being  controlled,  and  overpowered.  But  we  can 
readily  discern  how  very  various  must  be  the  special  subjects  of  these 
ideas,  according  to  the  amount  of  education  and  the  character  of  each 
individual,  their  antecedent  history,  and  the  impressions  which  have  been 
accidentally  made.  The  same  feeling  of  loss  of  self-control,  of  being  given 
over  to  foreign  and  peculiar  sensations  and  ideas,  which  awaken  in  tlic  .- 
credulous  peasant  the  idea  of  being  bewitched,  may  in  the  better  educated 
call  forth  the  idea  tluit  some  one  is  acting  upon  him  by  means  of  electri- 
city, magnetism,  or  chemistry.  To  the  one  it  seems  as  if  he  has  lost  all 
his  most  cherished  goods,  his  children,  his  relations,  and  his  fortune. 
This  he  firmly  believes,  and  fears  that  nothing  now  remains  for  him  and 
his  family  but  to  die  of  starvation.  Another  imagines  that  he  has  become  . 
bankrupt,  that  his  business  has  gone  from  him,  that  he  is  mixed  up  in 
the  most  serious  and  criminal  offences,  and  ceases  not  to  bewail  that  he 
has  reduced  his  family  to  the  most  abject  poverty  and  beggary.  At 
other  times  it  seems  to  the  patient,  when  he  feels  the  ciiange  which  has 
occurred  in  his  whole  mode  of  sensation,  and  experiences  the  impos- 
sibility of  maintaining  his  ordinary  share  of  worldly  duties  and  employ- 
ments— imagines  that  he  can  no  longer  be  a  man — that  he  is  gradually 
becoming  like  one  of  the  lower  animals,  or  that  he  is  even  already  trans- 
formed into  a  beast.  As  the  change  in  the  patient's  views  of  life  and 
morals  in  general  usually  gives  to  the  insanity  a  certain  color  and  expres- 
sion, so  long  as  the  natural  sensations  continue  the  same,  and  the  general 
relations  of  love  of  family,  interest,  friendship  (emotions  which  in  all 
times  most  actively  bear  on  the  human  heart)  remain,  so  also  the  deli- 
rium of  the  melancholic  presents  various  phases  at  different  epochs. 
The  fundamental  disorders  of  the  self-sensation  are,  however,  always  the 
same,  whether  the  melancholic  believes,  as  in  the  days  of  old,  that  Atlas, 
becoming  fatigued  with  his  burden,  may  at  any  moment  let  the  arch  of 
heaven  drop;  or  whether  he  imagines,  as  in  the  middle  ages,  that  he 
is  under  the  power  of  sorcerers,  ghosts,  and  witches;  or,  as  in  our  times, 
that  he  is  sought  after  by  the  police,  or  tliat  he  is  engaged  in  the  most 
disastrous  speculations,  etc. 


160  STATES    OF    MENTAL    DEPRESSION. 

As  to  the  manner  in  which  this  delirium  is  brought  about,  we  have 
already  several  times  pointed  this  out.  The  patient  experiences  a  feel- 
ing of  sadness.  At  first  these  fits  of  sadness  are  only  produced  under  the 
influence  of  vexatious  causes;  but  the  law  of  causality  demands  even  here 
.some  motive,  some  cause  for  this,  and  before  the  patient  has  had  time  to 
inquire  into  the  rationale  of  it,  there  arise  as  answers  all  sorts  of  mourn- 
ful thoughts,  dark  presentiments  and  apprehensions,  over  which  he  broods 
and  ponders  until  certain  ideas  have  become  strong  and  persistent  enough 
to  be,  at  least  for  the  time,  fixed.  Thus  these  delirious  conceptions  again 
possess  the  essential  character  of  aiienipts  at  explanatioii  of  the  special 
state. 

At  the  commencement,  and  in  many  cases  even  during  the  entire  course  of 
the  melancholia,  there  may  be  no  delirium,  properly  so-called.  The  patients  may 
be  able  quite  correctly  to  realize  their  own  condition  and  the  things  of  the  exter- 
nal world;  to  analyze  their  sensations  with  precision,  and  anxiously  desire  to  free 
themselves  from  them,  but  to  do  this  is  absolutely  beyond  their  power. 

A  mongst  the  most  marked  cases  of  melancholia,  there  is  one  most  important 
distinction  to  be  made,  viz.,  whether  the  patients  appear  to  be,  as  it  were,  in  a 
profound  dream,  or  whether  all  their  transactions  with  the  outer  world  are  car- 
ried on  as  if  they  were  quite  awake.  Cases  of  tlie  first  class  ordinarily  assume  a 
more  acute  character,  and  more  nearly  approach  that  form  known  as  "  melan- 
cholia with  stupor,"  the  prognosis  of  which  is  much  more  favorable  than  that  of 
those  which  fall  under  the  second  head,  which  usually  develop  themselves  slowly, 
and  are  much  more  chronic  in  their  course.  The  first  class  of  cases  may  termi- 
nate very  speedily,  as  if  the  patient  had  suddenly  wakened  up;  the  latter  never 
do  this. 

§  118.  Anomalies  in  the  sensibility  and  movement  frequently  accom- 
pany these  mental  disturbances.  These  are  at  times  indicated  (as  already 
mentioned,  §  49)  by  sensations  of  emptiness  in  the  head,  of  deadness  in 
the  head,  or  of  some  other  member,  or  even  of  the  whole  body;  some- 
times by  these  annoying  sensations  experienced  over  the  whole  surface  of 
the  skin,  and  suggest  to  the  sufferer  the  idea  that  some  one  is  electrifying 
him;  or,  finally,  by  hyperaesthesia  of  the  sight  and  hearing  (trembling, 
starting  at  the  slightest  noise — perhaps  a  fundamental  cause  of  the  so- 
called  panphobia). 

The  special  insanity  of  the  senses,  the  hallucinations  and  illusions,  have 
quite  the  character  and  impress  of  painful  emotional  perversion.     The 
patient  sees  the  preparations  for  his  punishment — he  hears  the  messengers 
of  justice  who  have  come  to  seize  him — he  perceives  himself  surrounded 
by  the  flames  of  hell — precipices  appear  to  open  under  his  very_  feet — 
spirits  come  to  annonnce  to  him  that  he  is  about  to  judged — he  is  pur- 
sued  by  voices  Avliich  address  him   in  the  most  abusive  and  niocking 
language,  etc.     A  young  melancholic  who  was  under  my  observation,  one 
day  saw  the  head  of  a  pig  staring  at  her  as  she  looked  into  the  mirror; 
and  for  long  after  she  continued  to  fancy  that  she  herself  had  been  trans- 
formed  into  such  an  animal.      Hallucinations  are   most  common  and 
most  varied  in  that  very  serious  form  of  melancholia,  in  which  the  patient 
continually  broods  over  his  own  misfortune,  and  is  wholly  wrapt  up  in  it; 
and  wliere  there  is  a  partial  suppression  of  consciousness  of  what  is  going 
on  in  the  external  world  (see  under  the  head  "Melancholia  with  Stu- 
por ").     We  often  meet  with  hallucinations  of  taste  and  smell,  the  for- 
mer particularly,  when  the  patient,  perceiving  a  metallic  taste  in  all  he  eats, 
has  the  idea  thus  suggested  to  him  that  some  one  is  endeavoring  to  poisou 
him,  or  that  a  charm  has  been  wrought  upon  his  food.     The  subjective 


STATES    OF    MENTAL    DEPRESSION.  161 

Tinpleasant  odors  lead  him  to  imagine  that  he  is  surrounded  by  dead  bod- 
ies, or  that  he  himself  is  in  a  state  of  putrefaction,  etc. 

With  the  appearance  and  increase  of  the  hallucinations,  the  patient 
commences  to  act  entirely  according  to  imaginary  relations,  and  conse- 
quently becomes  more  and  more  estranged  from  the  world.  These  hallu- 
cinations often  serve  as  the  object  of  new  explanations,  and  the  most 
gloomy  and  absurd  ideas  of  worlds  of  spirits,  of  machines  below  the  earth, 
which  exert  their  influence  upon  these  unfortunates,  etc.,  take  their  ori- 
gin in  these  perversions  of  the  senses  which  often  only  manifest  them- 
selves long  after  the  commencement  of  the  disease,  or  which  may  even 
never  give  any  outward  sign  of  their  presence. 

The  movements  of  the  melancholic  bear  the  impress  of  the  ruling  pain- 
ful emotions.  Generally  they  are  languid,  feeble,  or  constrained.  The 
patient  gladly  rests  in  bed,  or  keeps  the  whole  day  to  one  corner,  where 
he  sits  without  taking  the  sliglitest  notice  of  anything  that  is  going  on 
around  him.  Often  he  sits  absolutely  motionless,  as  immovably  fixed  as 
a  statue.  In  such  cases  the  limbs  are  perfectly  stiff,  and  offer  consi- 
derable resistance  to  any  attempts  to  give  them  another  position;  or  else, 
on  the  other  hand,  they  are  abnormally  flexible  and  mobile,  and  often 
retain  the  position  in  which  they  have  been  placed  (cataleptic  states). 
The  muscles  of  the  face  are  sometimes  the  seat  of  a  permanent  contrac- 
tion, the  features  are  fixed,  the  eyebrows  wrinkled,  the  angles  of  the 
mouth  drawn  down.  All  this,  joined  to  the  generally  grayish  livid  tint 
-of  the  skin,  gives  to  these  melancholies  almost  invariably  the  appearance 
of  great  age.  The  eyes  are  always  cast  downwards,  or,  on  the  other 
hand,  widely  open,  and  fixed  with  the  expression  of  suffering,  of  painful 
tension,  or  of  astonishment. 

An  essentially  different  deportment  is  presented  by  movements  in 
that  form  of  melancholia  where  the  inner  disquietude  is  also  expressed 
by  physical  restlessness  (melancholia  agitans),  in  which  there  usually  is 
a  confused  tumult  of  thought.  In  essentials,  however,  these  are  cer- 
tainly very  monotonous  and  of  small  variety  ;  and  it  is  through  this 
paucity  of  ideas,  this  want  of  fertility,  that  this  state  differs  from  mania.' 
At  other  times,  the  patient  keeps  up  a  perpetual  motion,  often  breaks 
out  into  fits  of  weeping,  and  constantly  wrings  his  hands.  Not  unfre- 
quently,  hemanifests  a  great  desire  to  wander  about  at  liberty,  to  make 
long  excursions,  and  to  visit  his  friends  and  relations  (melancholia  erra- 
bunda).  Often  while  walking  he  wrings  his  hands,  or,  becoming  violently 
agitated,  throws  his  arms  into  all  manner  of  wild  contortions.  We  may 
quite  correctly  recognize  in  these  two  different  modes  of  appearance  of 
the  morbid  mental  pain,  the  analogues  to  the  painful  emotions  of  the 
healthy  :  on  the  one  hand,  to  the  immobility  consequent  on  shock  or 
fright ;  on  the  other  hand,  to  the  physical  restlessness  and  agitatation 
(running  about  in  the  open  air,  etc.)  observed  in  these  in  this  frame  of 
mind. 

Hie  deviations  from  the  normal  standard  of  physical  health  are  valueless  for 
the  purpose  of  diagnosis  of  insanity  in  general,  or  of  any  one  form  of  mental  dis- 
ease, but  are  of  the  highest  importance  so  far  as  regards  its  etiology  and  treat- 
ment. These  deviations  are  by  no  means  constant,  and  do  not  always  present  the 
same  relation  to  insanity.  Sometimes  they  are  merely  the  symptoms  of  some 
malady  which  may  have  been  in  existence  for  a  considerable  time  previously, 
but  wliich  at  the  same  time  may  have  contributed  somewhat  to  the  production  of 


'  See  Richarz,  'Zeitschr.  f.  Psychiatrie,'xv.,  1858,  p.  28. 
11  J  ,        ,         ,y 


162  BTATES   OF    MENTAL   DEPBESSION. 

cerebral  disease  {e.  g. ,  arterial  affections).  Sometimes  they  are  accidental  com- 
plications; at  other  times  they  form  the  symptoms — and  these  latter  are  by  far 
the  most  important — of  the  cerebral  disease  itself.  To  these  latter  belong  par- 
ticularly— 

1st.  The  absence  or  diminution  of  sleep,  so  that  the  patient  either  remains  quite 
sleepless  or  feels  so  little  refreshed  by  his  sleep  that  he  affirms  that  he  has  not 
slept  (this  being,  in  fact,  a  prolonged  internal  wakefulness  with  drowsiness  of  the 
sensorial  functions).  He  often  has  disagreeable  dreams,  and  frequently  halluci- 
nations occur  at  the  moment  of  awakening. 

2d.  Painful  sensations  in  the  head;  c.  g.,  heat,  pressure,  weight,  vertigo,  a 
feehng  of  emptiness,  of  water,  etc..  in  the  skuU;  a  light-headedness  like  that  of 
drunkenness;  noises  in  the  ears;  sensations  similar  to  that  of  an  aura;  slight  con- 
vulsions of  the  muscles;  wandering  pains  in  different  parts  of  the  body — the  chest, 
vertebral  column,  epigastrium,  etc.,  insensibility  of  some  portions  of  the  skin; 
feelings  as  if  this  or  that  member  no  longer  belonged  to  him,  and  a  marked  dimi- 
nution of  the  sexual  desires.  Such  are  some  of  the  principal  symptoms  which 
indicate  that  some  change  has  taken  place  in  the  action  of  the  nervous  centres. 
These  sensations  often  present  the  most  marked  correspondence  to  the  mental 
affection.  For  example,  a  young  woman  suffering  from  melancholia,  aged  thirty- 
two,  whom  I  Iiad  an  opportunity  of  observing  in  the  year  1857,  complained  much 
of  neuralgic  pains  in  the  right  side  of  the  forehead,  the  right  supra-orbital  nerve 
being  peculiarly  sensitive.  Every  day  she  had  an  attack,  which  began  by  a  sort 
of  darting  above  the  right  eye,  and  then  the  whole  head  was  immediately  attacked. 
in  the  same  way;  the  tendency  to  melancholy  increased  rapidly,  and  the  patient 
became  completely  confused. 

3d.  Very  often  the  digestive  function  is  disordered,  and,  as  in  nearly  all  cases 
of  cerebral  disease,  constipation  is  present.  This  fact  may  lead  to  certain  errors 
in  the  etiology,  the  assumption  of  hypothetical  stoppages  or  infarctus.  while 
every-day  experience  teaches  us  how  easily  derangements  in  the  intestinal  canal 
are  brought  about  in  otherwise  healthy  individuals  ^vhen  any  painful  event 
occurs.  Occasionally,  of  course,  especially  at  the  commencement,  we  do  find 
some  unmistakable  signs  of  a  gastro-intestinal  catanh.  Oftener,  however,  we 
merely  find  the  tongue  loaded,  and  an  abnormal  appetite  present — either  much 
decreased  or  (and  this  is  more  common)  increased,  and  that  to  such  an  extent  as 
to  suggest  the  idea  that  the  sensation  of  satiety  is  utterly  lost.  The  surprising 
gluttony  of  some  patients  often  forms  a  singular  contrast,  almost  grotesque,  to 
their  state  of  profound  sadness.  Thus  we  may  see  them  hastily  gorging  huge 
pieces  of  cake,  and  at  the  same  time  loudly  bewailing  their  numerous  sins,  and 
grieviog  over  the  loss  of  their  soul's  salvation,  or  over  temporal  misfortunes. 
The  sensation  of  weight  at  the  epigastrium  which  we  have  observed  to  be  com- 
plained of  by  a  large  number  of  such  patients,  appears  to  arise  from  the  diaphragm 
or  the  abdominal  muscles.  Beyond  this  we  are  as  yet  unable  to  go  with  our 
explanation.  This  is  to  be  regretted,  because  it  often  appears  to  maintain  the 
feelings  of  anxiety,  and  we  might,  by  controlling  it,  essentially  ameliorate  the 
condition  of  the  patient.  Thus,  in  the  case  of  a  young  woman  whom  I  saw  in 
1857,  and  who,  after  severe  tartar-emetic  treatment  (for  pneumonia),  suffered  for 
a  long  time  from  symptoms  of  chronic  ulcus  ventriculi.  The  frequent  fits  of 
acute  melancholia,  with  tliis  feeling  of  anxiety,  accompanied  by  palpitation, 
maintained  a  certain  relation  to  overfulness  of  the  stomach,  errors  in  diet,  indi- 
gestion, etc.  TJie  refusal  to  take  food,  which  is  frequently  observ3d  in  the  case 
of  melancholies,  and  which,  when  long  persisted  in,  becomes  a  troublesome  com- 
plication on  account  of  the  forced  alimentation  and  consequent  defective  nourish- 
ment, often  arises  from  the  fear  which  these  unfortunates  entertain  of  being 
poisoned,  or  from  various  abnormal  sensations  which  they  experience  in  their 
rtomach;  as  if  their  intestines  were  closed  up,  or  there  were  no  room  for  mora 
bod;  or  as  if  appetite  had  completely  left  them.  At  other  times  they  refuse  to 
>at,  because  they  wish  to  die  of  hunger,  or  because  tliey  believe  that  by  thus 
starving  themselves  they  can  expiate  their  sins:  or  because  of  hallucinations, 
such  as  the  hearing  of  voices  which  command  them  not  to  eat,  etc.  These  ideas 
seem  sometimes  to  be  suggested  and  kept  up  by  serious  affections  of  the  intestmal 
mucous  membrane,  and  particularly  by  an  acute  catarrh,  extending  over  a  great 
portion  of  the  intestinal  tract.  But  this  refusal  of  food  is  also  not  unfrequentlj', 
as  Guislain  has  judiciously  observed  (' Legons  orales,'  p.  265)  only  another  form 
of  displaying  their  obstinacy — just  as  they  refuse  to  speak.  Or,  lastly,  it  may  be 
the  result  simply  of  imitation.     The  immediate  results  of  this  prolonged  absti- 


STATES    OF    MENTAL    DEPKESSION.  163 

nence  are  rapid  emaciation,  dryness  of  the  skin,  slowness  of  respiration,  slugreish- 
ness  of  the  bowels,  deficiency  of  urine. 

4th  The  nutrition  of  the  body  frequently  suffers.  The  patients  become  thin; 
the  skm  loses  its  moistness  and  fresh  appearance;  it  becomes  pale,  withers  ami 
dries  up.  In  the  normal  state  we  do  at  times  observe  an  analogous  condition  of 
the  skin  as  tlie  result  of  harassing  and  sorrowful  emotions;  yet  it  has  been  most 
justly  remarked  that  the  perversion  of  the  feelings  in  melancholies  never  pro- 
duces so  profound  an  effect  upon  the  constitution  as  severe  and  protracted  emo- 
tions certainly  do  in  those  who  are  in  perfect  health.  This  has  been  accounted 
for  by  the  fact  that  the  majority  of  melancholies  eat  more  and  digest  their  food 
much  better  than  persons  in  health  do  when  under  the  influence  of  profound  sor- 
row.  But,  on  the  otlier  hand,  when  such  patients  nuist  be  fed  by  force,  as  when 
they  refuse  their  food,  they  sink  rapidly  into  acute  marasmus,  often  associated 
with  severe  and  fatal  local  maladies,  e.  g.,  lobular  pneumonia,  gangrene  of  the 
lungs,  etc. 

5th.  The  respiration  is  frequently  prolonged,  incomplete,  and  difficult.  The 
patient  is  oppressed,  and  seeks  to  obtain  air  by  means  of  deep  sighs.  Palpitations 
of  the  heart  are  by  no  means  uncommon,  and  often  it  is  from  this  organ  that 
those  sensations  of  anxiety  proceed.  We  have  already  spoken  of  affections  of  the 
cu-culation,  and  of  their  importance  so  far  as  regards  the  development  and  main- 
tenance of  cerebral  disease,  Tlie  state  of  the  pulse  is  extremely  variable;  it 
is  often  very  small  and  slow.  The  feet  and  hands  are  often  constantly  cold,  par- 
ticularly in  those  who  never  move  about,  when  they  may  present  a  cyanotic  or 
leaden  hue. 

6th.  Derangements  of  the  menstrual  function.  Absence  and  irregularity  are 
very  frequent.  In  some  cases,  with  the  re-establishment  of  the  menses  we  see 
the  mental  affection  completely  disappear;  while  in  others  it  produces  no  effect 
whatever,  and  even  at  times  tends  greatly  to  aggravate  the  disease  (see  §  108). 

7th.  Anomalies  in  the  urinary  secretion  may  be  much  more  frequent  than  is 
generally  supposed.  Unfortunately,  any  reliable  researches  on  this  important 
subject  are  still  wanting.  The  secretion  of  tears,  in  spite  of  the  state  of  mental 
sorrow  under  which  the  patient  constantly  labors,  is  very  rarely  increased. 

Chronic  affections  of  the  viscera  very  often  develop  themselves  during  the 
course  of  melancholia,  as  tubercles  of  the  lungs,  affections  of  the  skin,  chronic 
intestinal  catarrh,  etc.  These  affections  sometimes  remain  latent  for  a  very  long 
time.  When  death  results,  it  is  generally  in  consequence  of  one  of  these  diseases. 
It  is  by  no  means  rare  to  see  a  fatal  issue  when  the  patients  refuse  their  food;  and 
in  melancholia  with  stupor,  death,  independent  of  this  circumstance,  sometimes 
supervenes  in  the  midst  of  an  access  of  the  symptoms  by  an  aggravation  of  the 
cerebral  torpor  and  paralysis,  and  sometimes  at  the  autopsy  in  such  cases  consid- 
erable oedema  is  found. 

§  119.  TJie  Course  of  the  simple  forms  of  melancholia  is  often  very 
acute  :  thus,  for  example,  in  those  cases  where  a  very  short  period  of 
painful  perversion  of  the  feelings,  accompanied  with  profound  anxiety, 
precedes  the  development  of  mania,  particularly  of  intermittent  mania! 
Usually,  however,  the  course  of  melancholia  is  chronic,  with  remissions  j 
more  rarely  with  complete  intermissions,  of  variable  duration.  I,  have 
once  seen,  in  a  woman  attacked  with  intense  melancholia  (ideas  of  com- 
plete loss  of  fortune,  of  forced  starvation,  etc. ),  a  complete  lucid  interval 
of  scarcely  a  quarter  of  an  hour's  duration  supervening  without  any 
issignable  cause,  and  terminating  quite  as  suddenly.  Naturally,  the 
temissions  are  of  more  frequent  occurrence  at  the  commencement  of  the 
jQelancholia,  and  also  on  the  approach  of  convalescence. 

Transformations  into  mania,  and  the  passage  from  this  again  into 
melancholia,  are  phenomena  by  no  means  rare.  Sometimes  the  disease 
represents  a  cycle  of  these  two  forms,  which  often  regularly  alternate  with 
each  other— "la  folic  circulaire,"  which  the  French  alienists  have  recently 
been  discussing.  Other  observers,  including  myself,  have  seen  cases 
where  regularly  at  one  particular  season— for  example,  in  winter— a  pro- 
found melancholia  has  superverned,  which  in  spring  passes  into  mania, 
which  again  in  autumn  gradually  gives  way  to  melancholia. 


r 


164  STATES    OF    MENTAL    DEPRESSION. 

The  name  "  folie  circulaire"  was  employed  for  the  first  time  by  Falret  (1851), 
who  has  most  correctly  brought  before  the  world  the  extreme  gravity  of  this 
form  of  mental  alienation.  Baillarger  ('  Ann.  Med.  Psych.'  1854,  vi.,  p.  369)  took 
much  trouble  to  explain  that  in  "  folie  circulaire"  there  are  not  two  different 
attacks — one  of  melancholia,  another  of  mania — but  that  both  are  mei'ely  two 
different  stages  of  one  and  the  same  attack;  chieflj'  because  of  the  fact  that 
between  the  melancholia  and  the  mania  there  is  no  complete  remission.  This 
author  gives  to  this  affection  the  name  of  "la  folie  a  double  forme."  In  some 
cases  there  has  been  observed,  and  this  too  during  a  continuance  of  several  years, 
a  regular  alternation,  lasting  for  a  day  or  for  several  days,  between  melancholia 
and  mania. 

A  very  moderate  degree  of  melancholia  with  considerable  remissions 
may  persist  for  many  years.  Snch  patients  very  rarely  come  into  asylums, 
or  at  least  only  during  an  exacerbation  or  an  intercurrent  attack  of  mania. 
They  may  generally  be  maintained  in  their  ordinary  rehitions,  and  are 
torments  to  those  who  surround  them,  and  objects  of  the  most  varied 
mistaken  speculation  on  the  part  both  of  pliysicians  and  of  the  laity. 

The  persistent  foi-m  of  melancholia,  when  of  moderate  intensity  and 
properly  treated,  lasts  usually  from  six  months  to  a  year.  Judging  from 
a  considerable  number  of  observations,  we  may  almost  regard  it  as  certain 
that  acute  intercurrent  diseases,  as  well  as  newly  developed  chronic  ones, 
frequently  exert  a  favorable  mfluence  upon  tlie  melancholia,  as  it  usually 
desists  with  their  api)earance.  To  the  former  chiss  (acute)  belong,  for 
example,  salivation,  the  development  of  an  exanthem,  intermittent  fever  ; 
and  to  the  latter  pulmonary  tubercle.  At  all  events,  however,  we  must 
not  look  upon  these  facts  as  having  the  significance  of  crises  in  the  old 
sense  of  the  term,  since  certain  neuroses  (such  as  spinal  affections, 
violent  toothache,  etc.)  certainly  do  moderate,  and  sometimes  even  cause, 
tlie  disappearance  of  the  cerebral  disease.' 

But  what  is  certainly  as  frequent  as  the  disappearance  of  the  melan- 
cholia on  the  accession  of  other  diseases,  is  its  persistence,  or  even  its 
increase;  or  the  insanity  may,  with  the  cessation  of  the  melancholia, 
merely  assume  another  form.  Thus,  for  example,  we  have  seen  a  young 
man  who  for  years  had  been  afflicted  with  profound  melancholia  with 
only  slight  remissions,  in  whom,  upon  the  appearance  of  a  severe  catarrh, 
accompanied  by  haemoptysis  (the  first  symptoms  of  pulmonary  tuber- 
culosis, which  rapidly  progressed)  and  acute  pain  along  the  entire  length 
of  the  spinal  column,  the  melancholia  yielded  to  a  gaiety,  equally  mor- 
bid, and  a  restless  cheerfulness.     Such  cases  are  far  from  rare. 

Convalescence  generally  takes  place  gradually,  with  successive  dimi- 
nution of  the  symptoms,  and  of  always  more  prolonged  periods  of  calm; 
return  of  former  desires  and  peculiarities;  frequently  with  simultaneous 
improvement  of  the  bodily  health. 

We  have  already  seen  that  melancholia  not  unfrequently  passes  into 
one  of  the  forms  of  mania;  but  further,  simple  melancholia,  or  melan- 
cholia Avith  stupor,  may  also  terminate  by  leaving  the  patient  in  a  state 
of  intellectual  weakness,  a  more  or  less  exaggerated  state  of  veritable 
dementia.  This  is  probably  owing  to  the  development  of  organic  altera- 
tions within  the  cranium.  Although  the  patient  may  have  regained  his 
physical  vigor,  yet  the  physiognomy  wears  an  expression  of  heaviness  and 
stupidity.  The  sadness  may  have  gradually  disappeared,  but  the  intel- 
lectual faculties  have  lost  their  energy.  Not  unfrequently,  there  are  also 
developed  states  of  more  or  less  profound  partial  dementia,  where  the 


'  See  the  cases  of  Brodie,  already  quoted  alx)ve. 


I 


I 


STATES    OF    MENTAL   DEPRESSION.  165 

patient  has  some  fixed  delirious  conceptions,  particulurly  certain  halluci- 
nations, through  which  he  is  led  to  believe  that  people  desire  to  poison 
liim,  that  he  is  the  subject  of  various  plots,  or  that  he  is  constantly- 
electrified,  etc.;  in  which  case  the  patient  is  almost  always  incurable. 
Such  patients,  laboring  under  this  partial  dementia,  states  of  mental 
weakness,  with  the  remains  of  melancholia  (and  mania)  and  hallucina- 
tions, generally  with  numerous  exacerbations,  in  the  form  of  one  or  otlier 
of  the  primitive  states  (apathy  alternating  with  turbulence,  a  modified 
sadness  with  a  gaiety  equally  superficial,  etc. ),  constitute  by  far  the  ma- 
jor portion  of  the  chronic  cases  met  with  in  asylums.  We  shall  enter 
more  into  detail  on  this  subject  when  we  come  to  consider  partial  demen- 
tia and  dementia.  At  first  the  condition  frequently  continues  for  a  long 
time  stationary  in  the  form  of  melancholia,  varied  only  with  slight 
changes  for  the  better,  only  again  to  relapse.  At  this  period  it  is  ex- 
tremely difficult  to  say  anything  with  certainty  as  to  the  curability  of 
such  patients;  but  when  this  state  of  melancholic  apathy  continues  for 
three  or  four  years  consecutively  without  remission,  recovery  is  extremely 
rare. 

Examples  of  simple  forms  of  melancholia  terminating  in  recovery: 

Example  XII. — Hypochondria,  profound  melancholia,  intermittent  fever; 
recovery. — N.  N — ,  a  parish  miuister,  get.  43,  of  strong  constitution,  was  in 
August,  1825,  received  into  the  asylum  at  Siegburg,  he  having  been  taken  ill 
in  March  of  that  year.  The  chief  symptoms  had  hitherto  consisted  in  an  expres- 
sion of  great  anxiety  and  restlessness;  amazed,  sceptical  glance:  pale  counten- 
ance; short  reapiratiou,  and  small  and  rapid  pulse.  He  accused  himself  of  hav- 
ing spent  a  disgraceful  life,  and  of  serious  misdemeanoi's.  In  some  lucid  moments, 
liowever,  he  could  correctly  appreciate  his  condition  (bleeding,  blisters,  nitre, 
emetics,  and  use  of  feriiiginous  water). 

On  admission,  his  glance  was  timid  and  unsteady;  the  expression  that  of 
anxiety  and  doubt;  the  abdomen  distended;  the  bowels  constipated,  and  skin  of 
an  earthy  hue.  The  patient  declared  tliat  he  was  torn,  crushed,  and  hewn 
to  pieces  (cream  of  tartar  with  sulphur,  light  mental  employment). 

In  September,  the  patient  became  gi-adually  quieter,  and  showed  less  inclina- 
tion to  complain  of  his  sorrowful  feelings.  Soon  he  complained  of  weai'iness  and 
headache,  and  there  now  appeared  attacks  of  intermittent  fever  of  the  tertian 
type.  On  each  feverish  day  he  continued  in  the  belief,  until  the  sweating  stage 
came  on,  that  he  would  immediately  die,  repeating  this  continually,  with  the 
most  intense  expression  of  anxiety  in  his  countenance  and  gestures.  When  it  was 
represented  to  him  that  he  had  said  and  believed  the  same  thing  on  the  preceding 
fever-day,  he  replied,  "It  is  quite  different  to-day;  to  day  I  must  die."  After- 
wards the  feverish  attacks  occurred  daily,  and  the  fear  of  death  became  less 
intense.  At  last  they  spontaneously  ceased,  and  with  them  disappeared  also  the 
accusations,  which  had  now  become  less  violent  than  formerly,  but  were  still  fre- 
quently repeated,  which  the  patient  made  against  himself  of  having  committed 
unpardonable  crimes,  and  the  presentiment  of  temporal  and  eternal  punishment 
which  therefore  awaited  him.  Only  a  certain  degree  of  hypochondriacal  self- 
torment  and  excessive  anxiety  regarding  the  state  of  his  physical  health 
remained,  for  a  short  time,  behind.  The  pulse  became  regular;  the  oedema  of 
the  legs  (which  came  on  during  the  last  attack  of  intermittent  fever)  and  the 
earthy  hue  of  the  skin  both  disappeared. 

He  voluntarily  and  cheerfully  engaged  in  some  intellectual  labor,  became 
happy  and  lively,  and  in  January,  1826,  left  the  asylum  completely  cured. 

The  following  statements  regarding  the  origin  of  his  disease  were  written  by 
the  patient  after  his  recovery:  "  From  my  youth  there  existed  in  me  a  hypochon- 
driacal state.  Even  before  I  entered  the  university  I  believed  that  I  had  con- 
sumption, and  the  assurances  of  the  physicians  to  the  contrary  were  fruitless. 
Many  disagreeable  events  inspired  me  with  di.strast  towards  men.  and  in  1820, 
when  I  was  condemned  to  inactivity  on  account  of  disease  of  the  eyes,  my  ordi- 
nary occupation  consisted  in  thinking,  the  ideas  being  often  very  sad,  and  such 
as  could  not  fail  to  exert  on  me  an  unfavorable  influence.  In  the  year  1822  a  fire 
took  place,  and  a  thorough  wetting,  which  I  there  received,  when  just  convales- 


166  STATES    OF    ]VrENTAL    DEPRESSION. 

cent  from  an  illness  of  several  weeks'  duration,  made  a  most  unfavorable  im^ 
pression  on  me.  From  that  time  the  stools  became  less  frequent,  and  diflficulty 
of  hearing  set  in.  In  1824,  I  was  oppressed  with  work,  and  very  low-spirited;  I 
ceased  to  take  exercise;  household  cares  weighed  heavily  upon  me,  and  I  lost  a 
newly -born  child.  From  that  time  forth  I  lost  all  cheerfulness  and  pleasure  in 
work.  After  preaching,  I  felt  fatigued  and  exhausted;  anxiety  and  sad  ideas 
came  over  me;  my  sleep  was  scanty  and  tormented  by  horrible  dreams,  after 
which  a  violent  shiver  ran  through  all  my  members.  Nevertheless,  I  considered 
myself  healthier  than  formerly;  the  dulness  of  hearing,  pains  in  the  limbs  and 
flatulence,  from  which  I  had  hitherto  suffered,  became  less  troublesome,  and  I 
had  no  disagreeable  sensations  after  meals.  It  did  not  occur  to  me,  therefore,  to 
seek  the  cause  of  my  sad  condition  in  my  own  body,  but  rather  in  my  entire  life, 
which  appeared  to  me  to  have  been  one  great  crime.  This  idea  did  not  originate 
gradually,  l)ut  entered,  if  I  remember  rightly,  my  mind  all  at  once  like  a  dream. 
Thus  I  explain  my  entire  state.  This  occurred  in  perfect  clearness  of  thought, 
confidence  in  others  and  in  myself.  The  entire  human  race  seemed  to  rise 
up  against  me,  to  throw  me  from  their  midst  with  the  most  shocking  torments, 
and  I  myself  was  my  greatest  enemy.  I  acknowledged  to  my  wife  that  I  had 
committed  the  most  fearful  crime  that  had  ever  been  perpetrated,  and  would  be 
torn  in  pieces  by  my  parishioners  as  soon  as  they  became  aware  of  it.  Tlie  per- 
formance of  my  duties  became  impossible  to  me,  and  my  anxiety  constantly 
increased.  The  leading  members  of  my  congregation  gave  me  the  best  assur- 
ances and  propositions,  but  still  I  considered  that  all  was  lost;  and  one  day  when 
I  fainted  at  a  meeting,  I  believed  that  I  had  done  so  willingly.  I  thought  that 
the  noise  of  the  stove  was  the  beating  of  drums,  and  believed  that  soldiers  were 
coming  to  carry  me  off.  Afterwards,  it  seemed  as  if  a  scaffold  stood  before  me, 
on  which  I  should  be  torn  in  little  pieces,  and  the  fear  of  execution  constantly 
pursued  me.  The  things  around  me  appeared  more  beautiful  and  brilliant  than 
usual;  all  men  seemed  wiser  and  more  clever;  I  considered  myself  in  the  deepest 
depths,  and  no  longer  capable  of  performing  anything.  I  sometimes,  only  for  a 
moment,  believed  that  I  nevertheless  might  still  be  delivered:  and  this  feeling 
was  generally  followed  by  great  sadness.  I  cannot  better  describe  my  state, 
towards  the  termination  of  the  disease,  than  that  of  one  who  has  awakened  from 
a  profound  dream,  and  cannot  immediately  convince  himself  that  it  has  been  a 
dream." 

(Much  abridged  from  Jacobi,  '  Beobachtungen  iiber  die  Pathologie  und  Thera- 
pie  der  mit  Irresein  verbundenen  Krankheiten,'  i.,  Elberfeld,  1830,  p.  141.) 

Example  XIII. — Melancholia;  recovery  with  the  return  of  the  menstrual  dis- 
chaige. — A  young  woman,  set.  19  (whose  mother  had  committed  suicide  during 
an  attack  of  profound  melancholia),  healthy  and  of  joyful  disposition,  had  men- 
struated regularly  since  she  was  fifteen  years  of  age,  and  from  her  sixteenth 
year  had  suffered  from  leucorrhoea.  Afterwards  her  feelings  were  affected  by  a 
love  affair  which  was  not  favorable  in  the  circumstances,  and  by  other  events; 
and  she  suddenly  became  ill  in  August,  1825.  She  presented  a  slight  degree 
of  imbecility;  frequently  laughed  without  occasion:  made  all  kinds  of  merry  hits, 
and  was  incoherent  in  her  speech  and  actions.  Her  glance,  expression,  and 
movements  were  lively  and  hasty;  the  belly  distended,  the  bowels  constipated, 
menstruation  scanty.  In  the  course  of  a  few  months  there  appeared  a  complete 
remission  of  the  mental  symptoms,  but  in  six  weeks  the  insanity  appeared  anew 
under  a  different  form. 

The  patient  seemed  a  prey  to  melancholic  anxiety,  either  sat  dumb  and 
motionless  and  lost  in  thought,  or  weeped  and  sighed,  occasionally  exclaiming, 
"What  a  misfortune!  what  have  I  done?"  She  refused  food;  her  appearance 
became  altered;  her  former  freshness  was  changed  into  an  earthy  hue;  she 
became  wrinkled,  and  her  strength  left  her.  The  beUy  was  hard  and  distended; 
the  stools  were  small  and  dry;  the  menses  disappeared;  the  leucorrhoea  continued. 
After  a  time  her  appetite  returned;  she  went  to  a  trough  containmg  hen's  meat, 
or  sought  elsewhere  raw  and  dirty  food,  which  she  secretly  devoured.  She  soon 
gained  a  little  strength  and  bulk. 'but  had  a  bloated  and  livid  appearance.  After 
the  mental  disorder  had  continued  for  eight  months  without  medical  aid,  the  girl 
was  admitted  in  August,  1826,  into  the  asylum  at  Siegburg.  Excepting  a  some- 
what scrofulous  habit  and  the  long-existing  leucorrhoea,  no  symptom  of  bodily 
disease  could  be  observed.  Her  movements  were  without  energy,  her  carriage 
drooping,  and  she  wept  continuously  all  day  long,  and,  indeed,  drew  such  deep 
sighs  and  made  such  lamentations,  that  it  seemed  as  if  every  moment  she  met 
with  something  terrible.     She  generally  slept  quietly  during  the  night;  she  re- 


STATES   OF   MENTAL   DEPRESSION.  167 

quired  to  be  somewhat  pressed  to  take  her  food.  The  mental  disorder  in  the 
patient  was  now  manifested  principally  by  the  exclusive  governing  mental  dis- 
position which  ruled  all  her  thoughts  and  paralyzed  her  will,  without  any  other 
mental  confusion  or  any  definite  morbid  direction  of  the  desires  being  evinced. 
The  disordered  digestion,  the  distention  and  hardness  of  the  abdomen,  together 
with  the  amenorrhoea  and  fluor  albus,  appeared  to  afford  the  most  important 
therapeutic  indications  (mild  and  regulated  diet,  baths,  occupation).  A  conva- 
lescent attended  to  the  patient  with  motherly  care,  gained  her  confidence,  and 
was  of  great  benefit  to  her. 

Towards  the  end  of  September  the  menses  began  to  appear,  but  the  abdomen 
continued  distended  and  hard.  The  patient  gradually  became  calmer,  wept  less, 
and  ate  voluntarily.  In  three  weeks,  the  menses  returned;  the  belly  lost  its  hard- 
ness; the  bowels  became  regular;  the  wrinkles  disappeared  from  her  face,  and  the 
expression  became  more  cheerful.  After  the  menses  had  again  returned,  on  the 
10th  of  November,  her  sorrow  and  tears  left  her.  Employment  was  her  only 
pleasure;  the  fluor  albus  gradually  disappeared;  her  health  became  gradually 
more  confirmed,  and  in  April,  1827,  she  was  dismissed  cured.  (Jacobi,  loc. 
cit.,  p.  198.) 

Example  XIV. — Melancholia,  with  tendency  to  suicide  and  hallucinations; 
suspected  nocturnal  j)ollutions.  Recovery  in  consequence  of  cauterizatio7i  of  the 
urethra. — Emil  G — ,  set.  23,  showed  formerly  high  mental  attainments,  and  at  the 
age  of  twenty-one  became  an  advocate.  His  figure  was  bent,  the  body  lean,  the 
muscles  soft,  the  skin  colorless,  the  countenance  void  of  expression,  the  eyes  dull 
and  turned  towards  the  ground;  the  voice  weak,  behavior  timid,  and  the  lower 
extremities  in  constant  motion.  Although  he  spoke  little  and  awkwardly,  yet  he 
made  the  following  clear  statement  in  writing  regarding  his  condition: — 

After  the  patient  had  been  addicted  to  onanism  from  his  twelfth  year,  there 
appeared  at  the  age  of  nineteen  a  change  in  his  character.  At  first  there  was  a 
gradual  mental  loathing  at  everything,  a  profound  general  ennui.  Hitherto  he 
had  seen  only  the  bright  side  of  life,  but  now  everything  was  viewed  from  the 
dark  side,  and  soon  the  idea  of  suicide  entered  his  mind.  In  a  year  after  this  the 
idea  left  him,  and  he  then  considered  himself  the  object  of  scorn  by  others.  He 
thought  that  everybody  laughed  at  his  appearance  and  his  manners,  and  he 
several  times  heard,  as  well  in  tbe  streets  as  in  the  house  amongst  his  relations 
and  friends,  reproaches  directed  against  him.  At  last  he  believed  that  aU  the 
world  insulted  him;  if  any  one  coughed,  sneezed,  laughed,  put  his  hand  to  his 
mouth,  or  a  pocket-handkerchief  before  his  face,  it  made  on  him  the  most  painful 
impression— sometimes  angry  emotions,  sometimes  deep  depression  and  an  invol- 
untary flow  of  tears.  He  was  indifferent  to  everything,  and  always  engrossed 
with  his  ideas;  besought  solitude,  and  society  was  painful  to  him.  He  owned 
that  he  may  have  had  hallucinations,  but  felt  convinced  that  his  ideas  were  not 
without  foundation;  that  his  countenance  was  somewhat  strange;  that  persons 
could  read  in  it  his  fears,  and  the  thoughts  which  tormented  him. 

He  now  experienced  a  weight  in  his  head,  a  sort  of  pressure  on  the  brain;  he 
was  weak,  passionless,  sleepy,  and  dull.  Every  movement  fatigued  liim,  and 
yet  he  had  the  constant  desire  to  change  his  position.  He  felt  that  he  had 
become  old;  for  the  last  few  months  his  depression  had  been  increasing;  for  the 
past  jive  years  nothing  had  made  on  him  a  cheerful  impression,  everything  had 
oppressed  and  annoyed  him;  he  was  anxious,  bashful,  perplexed,  incapable  of 
acting  or  of  speaking:  "The  Spirit  of  life  has  withdrawn  itself  from  me." 

For  the  past  nine  months,  the  patient  had  completely  renounced  the  j^ractice 
of  onanism,  and  yet  his  condition  became  every  day  worse. 

He  had  inveterate  constipation;  complete  absence  of  erections  and  sexual 
desires;  about  one  to  two  pollutions  in  a  month.  The  urine  always  contained 
a  copious  flocculent  sediment,  like  a  thick  decoction  of  barley,  and  decomposed 
rapidly.  After  each  stool,  a  viscid  fluid,  like  thick  gum,  appeared  at  the  orifice 
of  the  urethra.  The  urine  was  voided  frequently;  tliere  was  irritability  of 
the  seminal  ducts,  testicles,  and  particularly  of  the  urethral  mucous  membrane, 
and  redness  of  the  urethral  orifice.  Cauterization  of  the  neck  of  the  bladder  and 
prostatic  part  of  the  urethra  was  resorted  to.  This  was  followed  by  a  gradual 
improvement,  which  was  furthered  by  continuous  tepid  baths.  Complete  recov- 
ery and  re-establishment  of  the  sexual  function  resulted. — Lallemand,  'Des 
Pertes  seminales,'  i.,  p.  357. 


k 


168  STATKS    OF    MENTAL    DEPKESSION. 

§  130.  The  modes  of  expression  of  the  mental  pain  experienced  in 
melancholia  are  so  diverse  and  so  multifarious,  that,  founding  upon  these 
principal  d\&erences,  certai7i  forms  and  varieties  of  melancholia  have 
been  constituted. 

In  so  far  as  the  difference  extends  merely  to  the  form  and  subject  of 
the  delirium;  which  often  agree  with  the  most  salient  causes  of  the  men- 
tal affection,  tlie  classification  of  sucli  varieties  is  of  minor  importance. 
According  to  tliis  view,  we  have  to  note  the  following  chief  sub-forms: 

1st.  Melancliolia  religiosa  is  the  name  given  to  that  form  of  melan- 
cholia in  which  the  delirium  centres  chieily  upon  religious  ideas,  the 
patient's  principal  delusions  being  that  he  has  committed  fearful  sins,  the 
terror  of  being  punished  by  hell,  and  that  he  is  a  castaway,  etc.  It  is 
frequently  owing  entirely  to  external  accidental  influences  that  the  inter- 
nal feeling  of  anxiety  is  exhibited,  as  anxiety  on  account  of  sin;  or  that 
the  patient,  in  his  mournful  perversion,  seeks  the  consolations  of  religion, 
which  here  indeed  have  not  the  expected  influence,  but  frequently  only 
result  in  increasing  the  anxiety.  In  such  cases  we  must  beware  of  con- 
founding the  effect  with  the  cause.  If  it  can  scarcely  be  denied  that 
the  constant  calling  forth  of  such  ideas  of  contrition,  and  fears  of  the 
punishment  of  hell,  and  particularly  that  gloomy  and  ascetic  manner  of 
viewing  the  affairs  of  this  world,  do  paralyze  the  energy  of  the  soul,  favor 
the  ascendency  of  mournful  thoughts,  and  promote  in  weak  minds  a  state 
of  moral  distraction  and  sad  emotion  which  may  thus  most  essentially 
contribute  to  the  development  of  melancholia,  still,  in  the  vast  majority 
of  cases,  those  religious  delusions  of  the  melancholic  are  to  be  regarded 
as  symptoms  merely  of  an  already  existing  disease,  and  not  as  the  causes 
of  the  affection. 

This  form  of  religious  melancholia  must  be  carefully  distinguished  from  that 
other  form  of  insanity,  in  which  the  predominating  delusions  are  also  religious, 
but  assume  a  gay,  audacious,  and  exalted  form — where  the  patients  imagine  that 
that  they  are  either  God  himself,  or  are  most  intimately  related  to  God,  the 
angels,  and  heaven.  This  form  differs  widely  and  entirely,  in  a  psychological 
point  of  view,  from  melancholia,  and  we  shall  speak  of  it  when  we  come  to  con- 
sider the  foi'ms  of  exaltation  in  detail. 

The  symptoms  are  also  similar  in  that  interesting  form  of  melancho- 
lia in  which  the  sentiment  of  being  governed  and  overcome  manifests 
itself  in  the  idea  of  demoniacal  possession,  the  so-called  demono-melan- 
cholia,  which  is  met  with  in  all  countries  (in  France,  particularly,  it  is 
by  no  means  rare'),  and  of  which  recently,  in  our  own  country,  ignorance 
and  the  grossest  superstition  have  used  to  the  worst  ends. 

In  this  form,  this  foreign  evil  power  by  which  the  patient  imagines 
himself  to  be  governed  assumes  different  demoniacal  shapes,  according 
to  the  prevailing  superstitions  and  beliefs  of  the  epoch  and  country 
(devils,  witches,  etc.),  to  which,  as  he  may  probably  at  the  same  time 
experience  some  abnormal  sensations  in  different  parts  of  his  body,  a 
very  limited  seat  is  assigned  by  the  patient, — sometimes  one  half  of  his 
body — sometimes  his  head,  his  back,  or  his  chest,  etc.  It  is  not  uncom- 
mon to  see,  along  with  this,  convulsion  of  the  voluntary  muscles,  con- 

'  M.  Macario,"  Etudes  cliniquessurlaDemonomanie,"  '  Annal.  Med.  Psychol..' 
i.,  1843,  p.  400:  Esquirol,  translated  by  Bernhard.  i.,  p.  280.  See  also  on  this 
subject — Calmeil.  '  De  la  Folie.'  Paris,  1845,  i.,  p.  85;  Albers,  'Archiv.  f.  Physiol. 
Heilk.,'  xiii.,  1Hj4,  p.  234;  Portal.  'Mem.  sur  plusieurs  Maladies.'  ii.,  p.  110? 
Moreau,  '  Du  Hachich,'  etc.,  pp  336,  354;  Baiilarger,  'Annal.  Med.  Psychol.,'  vi,,. 
p.  152;  Schiitzenberger,  ib.,  viii.,  p.  261. 


STATES    OF    MENTAL    DEPKESSION.  IC^ 

tractions  of  the  larynx  whicli  alter  the  voice  in  a  striking  manner, 
anaesthesia  of  different  important  organs,  hallucinations  of  sight  and 
hearing.  This  delirium  is  at  times  accompanied  with  intermittent 
paroxysms  of  violent  convulsions,  evidently  analogous  to  epileptic,  or 
still  more  frequently  to  hysterical  attacks,  which  are  separated  by  inter- 
vals of  perfect  lucidity. 

That  form  of  melancholia  in  whicli  the  predominant  delusion  is  that  the  sub- 
ject of  it  is  possessed  by  some  demon,  appears  chiefly  in  females  (almost  always 
hysterical  women)  and  in  children.  The  most  easy  explanation  of  this  physio- 
logical phenomenon  is  found  in  those  by  no  means  rare  cases  where  the  trains 
of  thought  are  always  accompanied  by  a  feeling  of  inward  contradiction,  which 
quite  involuntarily  attaches  itself  to  them,  the  result  of  which  is  ii  fatal  division 
or  separation  in  the  personality.  In  the  more  developed  cases,  this  circle  of 
ideas,  which  constantly  accompanies  and  arrays  itself  in  opposition  to  the  actual 
thought,  asserts  a  perfectly  independent  existence;  it  sets  in  motion  the  mechan- 
ism of  speech,  exhibits  and  clothes  itself  in  words,  and  appears  to  have  no 
connection  with  the  (ordinary)  ego  of  the  individual.  Of  this  train  of  ideas 
which  acts  independently  on  the  organs  of  speech,  the  individual  giving  utterance 
to  them  has  no  consciousness  before  he  hears  them;  the  ego  does  not  perceive 
them;  they  spring  from  a  region  of  the  soul  which  is  in  obscurity  so  far  as  the 
ego  is  concerned;  they  appear  to  the  individual  to  be  utterly  foreign,  and  are  felt 
as  intruders  exercising  a  constraint  upon  his  thoughts.  Hence  uneducated  persons 
see  in  these  thouglits  the  presence  of  a  strange  being.  In  some  cases  we  find  in 
the  extravagant  discourse  of  these  women  or  children  a  vein  of  poetry  or  irony 
iitterly  at  variance  with  the  opinions  which  they  formerly  most  dearly  prized; 
but  usually  the  demon  is  a  very  dull  and  trivial  fellow. 

Since  the  publication  of  the  first  edition  of  this  work,  I  have  had  the  oppor- 
tunity of  studying  several  cases  of  demonomania  in  various  stages,  of  which  I 
shall  here  give  tivo  interesting  examples. 

Example  XV. — Attacks  of  mental  disorder,  occurring  every  two  or  three  days, 
X>resenting  particularly  the  character  of  ideas  of  opposition. — M.  S — ,  a  peasant, 
aet.  54,  had,  when  twenty -two  years  of  age,  every  night  for  three  mouths,  an 
attack  of  violent  nightmare  and  hallucinations  of  hearing.  At  the  age  of  thirty, 
she  gave  birth  to  a  child;  the  menses  never  reappeared,  and  severe  hasmorrhoidal 
disease  of  the  rectum  developed  itself.  The  appearance  of  the  patient  is  good, 
and,  on  tactile  examination,  nothing  more  than  slight  anteflexion  of  the  uterus  is 
found.  Wlien  she  was  between  thirty  and  forty  years  of  age,  there  gradually 
appeared  a  disease  occurring  in  paroxysms,  and  wiiich  became  more  and  more 
fixed.  The  attacks  occurred  every  two  or  three  days,  and  in  the  interval  the 
patient  was  perfectly  well.  They  commenced  with  pains  in  the  head,  loins,  and 
neck;  palpitation,  anxiety,  great  exhaustion;  occasionally  symptoms  of  globus  and 
hysterical  convulsions.  She  was  obliged  to  lie  in  bed,  became  completely  apa- 
thetic, could  no  longer  connect  her  thoughts,  and  there  was  manifested,  as  a 
mental  anomaly,  an  internal  contradiction  against  her  own  thoughts  and  con- 
clusions a  constant  immediate  opposition  against  all  which  she  thought  and  did. 
An  inward  "voice,"  which  she,  however,  did  not  hear  in  her  ear,  opposed 
everything  which  she  herself  would  do  (for  example,  even  against  the  mere  lying 
in  bed,  which  her  condition  renders  necessary),  especially,  however,  against  all 
elevation  of  the  sentiments — praying,  etc.  The  voice  is  always  wicked  when  the 
patient  would  do  good,  and  sometimes  calls  to  her,  but  without  being  heard 
externally,  "Take  a  knife  and  kill  yourself!"  The  patient,  who  is  a  clever 
woman,  says  on  this  subject,  that  she  almost  believes  that  a  strange  being,  a 
demon,  is  within  her,  so  certain  is  she  that  it  is  not  herself  who  does  this.  I 
took  the  patient  into  the  clinique  at  Tiibingen,  and  there  had  frequent  oppor- 
tunities of  observing  the  attacks.  During  them  she  seemed  much  heated,  con- 
gested, had  an  obscure  and  confused  expression,  was  not  feverish  (temperature 
normal).  The  attack  lasted  from  twenty-four  to  forty-eight  hours.  On  one 
occasion  at  the  commencement,  when  the  head  was  much  congested,  venesection 
to  a  small  amount  was  performed,  which  only  temporarily  relieved  her.  Th& 
hsemorrhoidal  affection  was  much  improved  by  the  use  of  an  electuary  of  pepper, 
but  the  attacks  continue  without  change.     (Original  observation.) 

Example  XVI. — Chronic  demonomayiia. — C.  S — ,  an  unmarried  peasant,  aet. 
48.  voluntarily  presented  herself  at  the  clinique,  because  she  was  possessed  by 
spirits.     Her  father  became  a  little  strange  as  he  advanced  in  years;  her  sister 


170  STATES    OF    MENTAL    DEPRESSION. 

and  sister's  son  are  insane.  The  patient  had  a  child  at  the  age  of  nineteen;  she 
nursed  it  for  three  years,  and  fell  into  a  state  of  anaemia,  with  extended  pains  of 
the  limbs,  and  sometimes  convulsions.  For  a  long  time  she  had  convulsive 
movements  of  the  mouth.  Three  years  after  the  first  appearance  of  the  disease 
(about  thirteen  years  ago),  "the  speaking  out  of  her "  commenced.  From  that 
moment,  all  kind  of  thoughts  or  vt^ords  were  expressed  unintentionally  by  the 
patient,  and  sometim?s  with  a  voice  different  from  her  usual.  At  first  it  seems 
to  have  been  not  so  much  opposing,  as  quite  indifferent  and  even  reasonable 
remarks,  which  accompanied  the  thoughts  and  language  of  the  patient:  for 
example,  "  it "  said,  "  Go  to  the  doctor,"  "  Go  to  the  priest,"  or  "  Tlius,  thus  you 
must  do  it,"  etc.  Gradually  these  indifferent  remarks  were  succeeded  by  other  more 
negative,  and  at  present  the  voice  sometimes  simply  confirms  what  is  said  by  the 
patient,  at  others  it  derides  and  mocks  it:  for  example,  when  the  patient  says 
anything  which  is  right,  the  voice  says  after  her,  "You,  that  is  a  lie;  you,  that 
you  must  keep  to  yourself."  The  tone  of  the  voice  in  this  sjieaking  of  "the 
spirit"  is  always  somewhat  (sometimes  entirely)  diffei-ent  from  the  ordinary 
voice  of  the  patient,  and  she  looks  upon  the  fact  of  her  having  another  voice  as  a 
leading  proof  of  the  reality  of  the  spirit.  "The  spirit"  often  commences  to 
speak  with  a  deep  bass  voice,  then  passes  to  a  pitch  lower  or  higher  than  the 
ordinary  tone  of  the  patient;  occasionally  it  passes  into  a  shai'p,  shrill  ciy,  which 
is  followed  by  a  short  ironical  laugh,  I  have  myself  often  observed  this.  Besides 
those  words  spoken  by  "  the  spirit,"  the  patient  heard  inwardly,  and  almost  in- 
cessantly, a  great  number  of  spirits  speaking.  Sometimes  she  had  actual 
hallucinations  of  hearing,  but  never  of  sight.  Praying  rendered  the  state  which 
we  have  described  still  worse;  it  increased  the  restlessness.  In  church,  however, 
she  could,  from  awe  of  tlie  congregation  and  clergyman,  restrain  the  voice  of  the 
spirit;  she  could  also  read  aloud  from  the  prayer-book  without  being  disturbed. 
Sometimes  her  discourse  had  a  slight  taint  of  nymphomania;  she  said  that  the 
spirits  caused  her  to  have  obscene  thoughts,  and  to  express  them:  she  had  pruritus 
pudendi.  The  ^latient  never  knows,  until  it  is  spoken,  what  the  spirit  would  say. 
Sometimes  tlie  power  of  speech  is  altogether  denied  her  for  a  certain  time.  In  all 
the  phenomena  which  we  have  described,  the  greatest  and  invariable  uniformity 
prevailed,  and  her  condition,  which  for  a  long  time  had  been  fixed  and  stationary, 
continued  the  same  during  the  short  period  during  which  she  was  under  treat- 
ment.    (Original  observation.) 

Example  XVII. — Convulsive  attacks,  icitli  ideas  of  possession  and  plurality 
cf  tlie personality,  of  short  duration,  in  a  child.'' — Margaret  B — ,  aet.  11,  of  lively 
disposition,  but  a  godly,  pious  child,  was  on  the  19th  January,  1829,  without 
having  been  previously  ill,  seized  with  convulsive  attacks,  which  continued  with 
few  and  short  intermissions  for  two  days.  The  child  remained  unconscious  so 
long  as  the  convulsive  attacks  continued.  She  rolled  her  eyes,  made  grimaces, 
and  performed  all  kinds  of  curious  movements  with  her  arms.  On  Monday,  the 
31st  January,  she  assumed  a  deep  bass  voice,  and  kept  repeating  the  words,  "  I 
pray  earnestly  for  you!"  When  the  girl  came  to  her  senses,  she  felt  tired  and 
exhausted.  She  was  perfectly  unconscious  of  what  had  passed,  and  merely  said 
that  she  had  been  dreaming.  On  the  evening  of  the  22d  January,  another  com- 
menced to  speak  in  a  tone  distinctly  different  fi-om  the  forementioned  bass  voice. 
This  voice  sjioke  almost  without  intermission  as  long  as  the  crisis  lasted,  that  is, 
for  half  hours,  hours,  and  even  longer  ;  and  was  only  occasionally  interrupted  by 
the  bass  voice,  which  still  repeated  the  forementioned  words.  In  a  moment  this 
voice  would  represent  a  person  different  from  that  of  the  patient,  and  perfectly 
distinct  from  her,  speaking  of  her  always  objectively  and  in  the  third  person. 
There  was  no  confusion  or  incoherence  in  the  words  of  the  voice,  but  great  con- 
sistency was  shown  in  answering  all  the  questions  logically,  or  in  skilfully  evading 
them.  But  that  which  principally  distinguished  these  sayings  was  their  moral, 
or  rather  their  immoral,  character.  They  expressed  pride,  arrogance,  mockery, 
or  hatred  of  truth,  of  God  and  of  Christ,  The  voice  would  say,  "  I  am  the  Son 
of  God,  the  Saviour  of  the  world — you  must  adore  me,"  and  immediately  afterwards 
rail  against  everything  holy — blaspheme  against  God,  against  Clirist,  and  against 
the  Bible ;  express  a  violent  dislike  towards  all  who  follow  what  is  good ;  give 
"vent  to  the  most  violent  maledictions,  a  thousand  times  repeated,  and  furiously 
rage  on  perceiving  any  one  engaged  in  prayer,  or  merely  folding  their  hands.     All 

'  We  give  the  case  as  narrated  by  the  patient  in  order  to  show  the  artlessness 
of  the  story.  See  also  ■what  is  said  further  on  regarding  the  psychical  condition 
during  an  epileptic  attack. 


STATES    OF    MENTAL    DEPKESSION.  171 

this  might  be  considered  as  symptoms  of  a  foreign  influence,  even  although  the 
voice  had  not,  as  it  did,  betrayed  the  name  of  the  speaker,  calling  it  a  devil. 
Whenever  this  demon  wislied  to  speak,  the  countenance  of  the  girl  immediately 
and  very  strikingly  changed,  and  each  time  presented  a  truly  demoniacal  expres- 
sion, which  called  to  mind  the  scene  in  the  '  Messiade,'  of  the  devil  oflfering  Jesus 
a  stone. 

On  the  forenoon  of  the  26th  January,  at  11  o'clock,  the  very  hour  which,  ac- 
cording to  her  testimony,  she  had  been  told  by  an  angel  several  days  before  would 
be  the  hour  of  her  delivery,  these  attacks  ceased.  The  last  thing  which  was  heard 
was  a  voice  from  the  mouth  of  the  patient,  which  said,  "Depart,  thou  unclean 
spu-it,  from  this  child  I— knowest  thou  not  that  this  child  is  my  well-beloved  ?  " 
Then  she  came  to  consciousness. 

On  the  31st  January,  the  same  condition  returned  with  the  same  symptoms. 
But  gradually  several  new  voices  appeared,  until  the  number  had  increased  to 
six,  differing  from  each  other  partly  in  their  tone,  partly  in  their  language  and 
subject;  therefore  each  seemed  to  be  a  voice  of  a  special  personality,  and  was 
considered  as  such  by  the  voice  which  had  been  already  so  often  heard.  At  this 
period,  the  violence  of  tiie  fury,  blasphemy,  and  curses  reached  their  highest 
degree;  and  the  lucid  intervals,  during  which  the  patient  had  no  recollection  of 
what  had  occun-ed  in  the  paroxysm,  but  quietly  and  piously  read  and  prayed, 
were  less  frequent  and  shorter  in  duration. 

On  the  9th  Febiniary ,  which,  like  the  31st  January,  had  been  announced  to  her 
as  a  day  of  delivery,  this  most  lamentable  trouble  came  to  an  end,  and,  as  on  the 
former  date,  after  there  had  proceeded  from  the  mouth  of  the  patient  the  words, 
"  Depart,  thou  unclean  spirit ! "  "  This  is  a  sign  of  the  last  time  ! "  the  girl  awoke 
and  since  then  has  continued  well.  (Kerner,  'Geschichten  Besessener,'  Stutte., 
1834,  p.  104.) 

§  121.  2.  It  is  not  uncommon  to  meet  with  melancholies  who  imagine 
that  they  have  entirely  lost  their  personality,  and  that  they  are  changed. 

Melancholia  metamoiyhosis. — We  have  already  adverted  to  those  ideas 
which  depend  npon  general  and  partial  dys-  or  anaesthesias;  as  where  the 
patient  imagines  that  he  is  dead,  that  his  limbs  are  made  of  wood,  etc.  ; 
and  also  to  those  delirious  ideas,  proceeding  from  hallucinations,  of  being 
transformed  into  some  unsightly  beast.  But  of  much  more  interest,  as 
well  in.  a  psychological  as  in  a  pathological  point  of  view,  are  those  cases 
in  which  the  sufferer  believes  that  he  has  changed  his  sex,  men  imagining 
themselves  to  be  women,  and  vice  versa.  This  delusion,  it  is  true,  is  by 
no  means  confined  specifically  to  melancholies,  but  it  may  be  developed 
during  the  course  of  this  disease,  and  appears  in  many  cases  to  be  con- 
nected with  a  disease  of  the  genital  organs,  in  which  the  sexual  sensa- 
tions disappear. 

Thus,  Lallemand  speaks  of  a  patient  who  imagined  himself  to  be  a  woman,  and 
wrote  letters  to  an  imagined  lover.  The  autopsy  discovered  enlargement  and 
induration  of  the  prostate  gland,  abscesses,  also  obliteration  of  the  ductus  ejacu- 
latorii,  with  dilatation  of  the  vesiculas  seminales  and  of  the  vas  deferens.  ('  Dea 
Pertes  seminales,'  i.,  p.  64.) 

M.  Leuret  also  records  some  facts  concerning  individuals  who  imagined  that 
they  had  changed  their  sex.  In  general,  such  cases  are  rare  ;  it  is  more  common 
to  find  in  the  French  asylums,  e.  g.,  the  Salpetriere,  the  delusion  that  the  other 
female  patients  are  changed  into  men. 

§  122.  3.  Another  variety  of  melancholia  is  that  form  which  is 
characterized  by  a  longing  for  one's  native  land,  and  by  the  predominance 
of  those  ideas  which  refer  to  a  return  to  one's  home — Home-sickness. 
An  analogous  affection  is  sometimes  developed  in  prisoners  by  want 
of  employment  and  frequently  also  by  the  co-operating  influence  of  bad 
nourishment,  damp  cells,  and  onanism.  Nostalgic  melancholia  is  som- 
times  accompanied  by  symptoms  of  congestion  of  the  head,  and  even 
of  cerebral  inflammation  (Larrey)  ;  in  this  form,  too,  the  same  kind  of 
hallucinations  appear  (visions  of  home  scenes,  etc.).     Not  unfrequently, 


172  STATES    OF    MENTAL    DEPRESSION. 

we  see  indivichials  affected  with  a  greater  or  less  degree  of  nostalgia 
commit  acts  of  violence  (for  example,  the  murder  of  young  children, 
incendiarism,  etc.,  by  servants).  Those  acts  proceed  more  frequently 
from  evidently  selfish  motives,  as  from  the  desire  to  escape  from  a  forced 
and  painful  position,  thati  from  the  impulse,  which  also  comes  involun- 
tarily in  the  melancholic,  to  procure  a  certain  degree  of  solace  through 
the  perpetration  of  some  frightful  deed. 

Naturally,  home-sickness  is  not  always  a  mental  disease  :  this  is  of  impc^rtance 
in  a  medico-legal  point  of  view.  In  itself  it  is  a  mournful  disposition  of  spirit 
suggested  by  external  circumstances.  It  becomes  insanity  vs^hen  this  disposition 
so  strongly  impregnates  all  the  faculties  of  tlie  mind  as  utterly  to  exclude  the 
entrance  of  any  other  senf^iment,  and  when  it  is  accompanied  by  delirious  con- 
ceptions and  hallucinations;  a  state  in  which  physical  derangements— e:.  g.,  loss 
of  appetite,  emaciation,  etc. — are  seldom  absent.  In  short,  home-sickness  ought 
inforo  to  be  regarded  as  a  mental  af/ection  only  when  it  presents  the  usual  signs 
of  insanity.  The  want  of  reflection  which  :s  the  most  important  point  in  concrete 
cases,  ought  not  to  be  admitted  when  ihe  individual  is  perfectly  competent  to 
engage  in  his  usual  avocatior::  and  perform  his  duties,  ac  is  the  case  with  many  of 
those  young  incendiaries  aiflicted  wiMi  home-sickness. 

It  is  of  more  importance  to  distinguish  various  form  of  melancholia 
according  to  the  difereni  relation  of  ^lie  emotional  nature  ;  of  the  will 
and  of  the  actions."  Thuc  the  conditions  which  we  have  just  beon  con- 
sidering may  present  important  modifications  in  tw- >  different  and,  in 
some  degree,  opposite  ways.  On  tiie  one  hand,  they  may  proceed  to  a 
state  of  still  deeper  selfyconcentration  with  complete  loss  of  will,  or  more 
usually  with  convulsive  tenacious  effort.  On  the  other  hand,  in  these 
states,  new  desires  and  new  movements  of  the  will  may  appear,  corre- 
sponding to  the  general  negative  disposition,  which  either  manifest  tiiem- 
selves  only  in  one  isolated  act  of  violence,  or  in  a  continual  outward 
restlessness  and  excitement ;  when  the  melancholia  passes  into  the  form 
of  mania. 

According  to  this  view,  we  may  consider,  as  the  principal  forms  of 
melancholia,  the  following  : 

1st.  Melancholia  where  the  subject  of  it  is  lost  in  self-co7iteniplation. 
Melanclwlia  with  stupor  (usually  described  by  the  French  writers  Georget, 
Etoc-Demazy,  Baillarger,  etc.,  by  the  not  very  appropriate  name  of 
''stupidite,"  though  properly  understood  by  the  latter  according  to  its 
nature'). 

2d.  Melancholia  with  manifestation  of  negative  destructive  tenden- 
cies, particularhj  with  certain  acts  of  violence  sometimes  directed  against 
self  (the  so-called  suicidal  mania),  sometimes  against  other  persons  and 
inanimate  objects  (homicidal  mania,  and  monomania  of  destruction  so 
far  as  these  cases  are  connected  with  melancholia). 

3d.  Mela7icholia  accompanied  by  persistent  excitement  of  the  will,  in 
the  stage  of  transition  into  mania. 


*a^ 


Section  III. — Melancholia  With  Stupor. 

%  123.  That  form  of  melancholia  in  which  is  represented  the  highest 
degree  of  self-absorption  under  the  outward  form  of  stupe)r,  is  not  only  of 
the  highest  theoretical  importance  on  account  of  the  well-marked  mental 


'  Baillarger,  "  De  FEtat  designe  chez  les  Alienes  sous  le  nom  de  Stupidite  ;"■ 
'AnnalMed.  Psychol.,'  i.,  1843,  pp.  76  and  256.  A  later  article  by  the  same 
physician  ('  Annal.  Med.  Psychol.,'  1853,  v.,  p.  251)  bears  the  title,  "  De  la  Melan- 
cholie  avec  Stupeur."    Guislain  included  this  condition  in  part  under  "  Ecstasy. 


STATES    OF    MENTAL    DEPRESSION.  3  73 

symptoms,  and  of  the  very  characteristic  anatomical  lesions  in  the  brain, 
which  exist  in  some  cases;  but  on  account  of  its  being  so  often  and  so 
readily  confounded  with  dementia,  which  may  lead  to  serious  errors  both 
as  regards  2:)rognosi3  and  treatment. 

Eeally  the  patients  in  the  higher  degree  of  these  states  present  to 
appearance  the  very  picture  of  dementia.  They  are  perfectly  dumb, 
completely  passive,  they  only  move  when  compelled  by  some  strong  ex- 
ternal motive;  their  whole  bearing  is  that  of  stupidity;  the  expression  is 
that  of  general  profound  mental  oppression,  of  a  veritable  annihilation; 
but  the  glance  of  such  patients  does  not  indicate  the  nullity  proper  to 
dements — it  expresses  a  painful  emotion,  sadness,  anxiety,  or  concentrated 
astonishment.  In  the  more  advanced  degrees  there  generally  exists  an- 
aesthesia, sometimes  partial'  and  sometimes  general,  of  the  surface  of  the 
skin,  and  a  condition  of  the  higher  organs  of  sense  whereby  the  impres- 
sions of  sight  and  of  hearing  are  rendered  quite  indistinct  and  confused, 
and  frequently  so  perceived  as  if  they  came  from  a  distance;  perhaps  in 
some  cases  there  is  an  increase  of  that  cerebral  paresis  of  sensation  of 
which  we  have  already  spoken  several  times  (§  50,  §  114). 

The  voluntary  muscles  appear  at  times  to  be  perfectly  rigid  and  on 
the  stretch,  sometimes  benumbed;  it  is  not  uncommon  to  find  such  pa- 
tients in  a  cataleptic  condition;  and  many  of  the  observations  concerning 
so-called  catalepsy  belong  in  i-eality  entirely  to  this  form.  The  mobility 
of  the  members  under  the  control  of  tlie  will  is  always  very  much  di- 
minished, occasionally  almost  suppressed.  There  is  a  condition  like  that 
of  restraint  of  all  the  motory  functions  of  the  brain. 

In  such  circumstances,  the  patients  have  in  the  majority  of  cases 
lost  all  consciousness  of  time  and  place,  as  well  as  the  appreciation  of 
their  bodily  necessities:  consequently,  they  are  in  the  highest  degree  un- 
clean— require  to  be  fed,  to  be  clothed,  to  be  put  to  bed,  etc.  Usu- 
ally they  then  emaciate  rapidly,  marasmus  speedily  comes  on,  and  death 
is  by  no  means  uncommon  in  this  form  of  melancholia. 

In  what  condition  is  the  intellectual  life  of  the  sufferer  during 
the  course  of  this  disease?  On  this  subject  certain  patients  have,  after 
their  recovery,  given  us  the  most  remarkable  information.  So  far  from 
experiencing  that  total  psychical  void  which  is  proper  to  dementia, 
the  mind  in  the  great  majority  of  instances  retains  its  normal  activity. 
But  the  patient,  owing  to  this  abnormal  condition  of  the  sensorial  per- 
ception, unconscious  of  what  goes  on  around  him,  lives  in  an  imaginary 
world.  So  far  as  he  is  concerned,  all  reality  has  disappeared,  all  around 
him  is  effaced  and  transformed.  An  intense  internal  anxiety  constitutes 
the  fundamental  state  which  torments  him  almost  to  suffocation,  and 
from  this  proceed  ideas  of  being  threatened  every  moment  with  mis- 
fortunes; as  houses  going  to  fall  upon  him,  of  the  world  coming  to  an  end, 
of  total  annihilation  of  everything,  as  well  as  certain  delusions  of  having 
committed  some  frightful  crime,  of  depravity,  etc. 

The  sufferer  is  unable  to  exert  his  will,  and  therefore  feels  the  im- 
possibility of  freeing  himself  from  the  terrors  which  threaten  him  on  all 
sides.  Very  frequently  he  cannot  afterwards  tell  why  he  was  incapable 
of  the  least  exercise  of  will,  why  he  could  not  reply,  why  he  could  not 
cry  out.  Esquirol'^  has,  however,  acquainted  us  with  the  interesting  de- 
claration of  a  patient  after  his  recovery.     "This  want  of  activity  was 

»  Sc.  Pinel,  '  Traite  de  Pathol.  Cerebrale,'  Paris,  1844,  p.  250. 
'  'Geisteskrankheiten.'  von  Bernhardt,  ii.,  p.  125. 


17Jr  STATES    OF    MENTAL    DEPRESSION. 

due  to  the  fact  that  my  sensations  were  too  feeble  to  call  forth  an  exer- 
cise of  will."  But  this  absence  of  will  is  most  evidently  manifested  in 
in  the  utter  passiveness,  inactivity,  and  immobility  of  tlie  patients;  as 
well  also  by  the  intercurrent  fits  of  intense  activity  which  sometimes 
occur,  in  the  same  way  as  many  patients  may  have  now  and  then  a 
sliort  moment  of  consciousness,  and  obtain  a  glimjjse  of  the  actual 
world. 

Very  often  this  external  insensibility,  this  suppression  of  the  effort, 
and  the  exclusive  sad  delirium,  are  accompanied  by  hallucinations  and 
illusions  of  the  same  nature.  The  patient  hears  voices  which  seem  to  re- 
proach him,  to  insult  him,  and  to  threaten  him  with  death;  or  a  confused 
noise  of  bells,  trumpets  and  cannons,  etc.  He  sees  witches,  funeral  pro- 
cessions, subterranean  vaults,  volcanic  craters,  which  appear  to  yawn  at 
his  very  feet.  He  sees,  also,  the  most  cherished  of  his  relations  martyred, 
etc.  He  fancies  himself  in  a  desert,  in  hell,  chained  to  the  galleys;  in  one 
word,  the  entire  subjective  change  which  is  produced  in  his  sensorial  per- 
ceptions, and  the  consequent  transformation  in  all  impressions,  causes  all 
external  objects  which  he  still  perceives  to  appear  only  in  the  forms  and 
figures  colored  by  the  predominating  sentiment  (see  examples) — a  state 
which  is  also  characterized  by  a  considerable  degree  of  confusion  of 
ideas. 

In  many  ways  this  condition  presents  the  greatest  similarity  to  a  state 
of  half-sleep  or  dream.  The  production  of  emotions  of  ideas  and  thoughts 
of  a  mournful  and  painful  description  find  an  exact  analogue  in  the  ap- 
pearance of  peculiar  new  and  disagreeable  sensations  (formication,  prick- 
ing, cold)  in  the  deadened  sensory  nerves;  and  we  shall  see  that  this 
comparison  is  only  the  more  true  because  in  a  large  proportion  of  these 
cases  we  are  able  to  prove  the  existence  of  an  evident  pressure  upon  the 
brain.  The  patients  themselves,  when  they  again  commence  to  become 
more  lively,  to  feed  themselves,  and  to  do  a  little  work — in  short,  to  con- 
valesce— are  as  astounded  as  if  they  were  just  waking  up,  and  often  ask 
where  they  are,  and  only  gradually  recover  themselves.  They  then  com- 
pare their  actual  state  to  a  dreadful  dream,  and  their  convalescence  to  an 
awakening  therefiom. 

§  124.  Still,  there  is  not  always  present  during  the  course  of  this  form 
of  melancholia  such  a  multiplicity  of  painful  sensations,  ideas,  and  im- 
ages as  have  been  mentioned.  In  many  cases  it  is  rather  a  half-sleeping 
state,  without  distinct  dreams  or  lively  hallucinations — a  state  of  self- 
absorption,  of  estrangement  from  the  outer  world,  in  which  little  else  is 
perceived  than  the  feeling  of  profound  internal  disturbance  and  absence 
of  will;  where  the  intellectual  faculties,  it  is  true,  seem  to  be  in  a  state  of 
abeyance,  but  yet  the  patient  retains  the  consciousness  of  his  condition. 
Perhaps,  indeed,  it  may  be  because  the  patient  cannot  give  a  good  ac- 
count of  his  state,  or  at  best  can  only  feebly  recall  it,  that  psychical  ano- 
malies so  striking  m  themselves  are  so  little  known. 

This,  too,  may  serve  to  explain  why  several  distinguished  observers 
(Esquirol,  Georget,  Ellis')  have  considered  these  conditions  to  be  de- 
mentia, and  the  fact  propounded  by  M.  Etoc-Demazy  (1833),  and  most 
erroneously  generalized  by  Sc.  Pinel  (1840,  1844),  that  in  certain  of  these 
patients  a  cerebral  oedema,  and  consequently  compression  of  the  brain, 
is  by  no  means  unfavorable  to  this  view  of  the  matter.  But,  in  the  first 
place,  this  cerebral  oedema  is  by  no  means  constant;  and  further,  the  de- 

'  Ellis,  'Traite,  etc.,  par  Archambault,'  Paris,  1840,  p.  199. 


STATES    OF    MENTAL    DEPRESSION.  175 

clarations  made  by  patients  after  their  recovery  are  of  themselves  sufficient 
most  unequivocally  to  clear  up  the  difference  between  this  form  of  mel- 
ancholia and  dementia.  There  is  the  same  difference  between  melan- 
cholia with  stupor  and  dementia,  as  between  temporary  diminution  in  the 
sensory  nerves  of  sensibility  to  external  impressions,  with  pain  and  new 
abnormal  sensations  on  the  one  hand,  and  complete  and  persistent  anes- 
thesia on  the  other.  But  as  the  two  conditions  may  depend  on  the  same 
cause  (compression),  and  while  it  is  not  rare  to  see  these  two  states  suc- 
ceed each  other,  and  rapidly  transformed  the  one  into  the  other,  so  also 
this  form  of  melancholia,  as  melancholic  stupidity,  may,  when  it  lasts 
for  a  lengthened  period,  become  transformed  into  actual  persistent  weak- 
ness of  the  intellectual  faculties,  with  cessation  of  the  painful  emotions, 
into  dementia, — into  conditions,  therefore,  where  the  intellectual  activity 
is  not  merely  restrained,  but  actually  persistently  and  most  profoundly 
destroyed. 

That  which  outwardly  distinguishes  these  two  states  over  and  above 
the  expression  of  the  countenance,  and  particularly  of  the  aspect  of  the 
patient,  is,  first,  in  many  cases  the  primary  and  very  rapid  development 
of  this  melancholia  with  stupor,  and  further,  the  almost  universal  emaci- 
ation, the  sallow  complexion,  the  irregularity  of  the  secretions,  the  Avant 
of  sleep,  the  great  opposition  to  passive  movements,  the  refusal  to  take 
food,  and  the  attempts  to  commit  suicide — phenomena  which  are  never 
met  with  in  dementia. 

When  melancholia  with  stupor  does  not  pass  into  dementia,  it  is 
rarely  prolonged  beyond  a  few  months;  many  sufferers  from  it  recover, 
and  recover  generally  quickly  as  if  awaking  from  a  dream.  Drastics  and 
vesicatories  seem  in  many  cases  to  be  of  the  utmost  service.  Death 
sometimes  supervenes  as  the  consequence  of  an  augmentation  of  the  ap- 
pearances of  cerebral  compression  (very  slow  pulse,  etc.);  sometimes,  also, 
as  the  termination  of  a  gradually  increasing  marasmus,  depending  upon 
intense  intestinal  catarrh  or  pulmonary  phthisis.  I  once  saw  a  case  of 
suicide  in  this  form  of  melancholia. 

Melancholia  with  stupor  is  sometimes  developed  as  a  primary  affec- 
tion, especially  in  the  case  of  young  female  patients,  as  the  consequence 
of  a  profound  mental  shock:  sometimes,  also,  it  makes  its  appearance 
after  attacks  of  epilepsy,  of  mania,  or  it  may  even  alternate  with  the 
latter. 

Example  XVIII. — Melancholia  with  stupor  conseciitixie  to  remittent  fever  ; 
recovery. — A.  B — ,  set.  25,  a  government  official,  was  admitted  into  Charenton  on 
the  12th  August,  1833.  At  the  age  of  fifteen  he  had  an  attack  of  insanity,  and 
another  at  the  age  of  twenty-two  ;  the  first  lasted  for  six  weeks,  the  latter  for 
fourteen  days.  B —  had  been  for  six  weeks  ill  with  intermittent  fever,  and  sud- 
denly, without  any  appreciable  cause,  the  insanity  appeared  after  several  days' 
suffering  from  violent  headache.  The  symptoms  were  those  of  cerebral  inflamma- 
tion ;  convulsions  occurred  several  times  in  three  weeks,  and  on  more  than  one 
occasion  the  patient  attempted  suicide.  On  admission,  the  countenance  was  pale; 
the  eyes  fi:xed,  widely  open,  and  directed  to  the  ground  :  his  physiognomy  was 
expressionless  and  dull.  B —  remained  the  whole  day  sitting  in  the  same  place, 
and  appeared  quite  strange  to  all  around  him.  To  questions  which  had  to  be 
several  times  repeated  and  spoken  in  a  loud  voice,  he  replied  in  monosyllables 
slowly  and  softly  pronounced.  In  walking,  he  supported  himself  on  the  wall,  or 
on  other  persons,  and  proceeded  very  slowly :  he  offered  resistance  when  taken  to 
the  bath.  Memory  appeared  to  be  completely  suspended  ;  he  required  to  be  fed, 
and  was  very  dirty  in  his  habits.  The  cutaneous  sensibility  was  dull,  the  sleep 
prolonged,  and  the  appetite  great.  Esquirol  prescribed  a  blister  to  the  nucha. 
B —  complained  of  the  pain,  and  immediately  began  to  improve.  His  replies 
became  longer  and  more  loudly  spoken  ;  he  declared  that  he  could  not  develop 


176  STATES    OF    MENTAL    DEPRESSION. 

his  ideas,  something  prevented  him.  The  physiognomical  expression  and  dirty 
habits  still  continued.  Sometimes  he  burst  into  loud  laughter  when  he  caught  a 
glimpse  of  a  patient  clothed  in  a  linen  blouse.  By  the  15th  of  October  the  im- 
provement was  very  evident;  he  was  cleanly,  and  had  begun  to  play  on  the  piano. 
In  December  his  former  lively  expression  returned,  and  his  intellect  appeared 
completely  developed.  B —  compared  the  state  in  which  he  had  been  for  the  past 
three  months  to  a  prolonged  dream.  All  around  him  seemed  changed  :  he 
believed  in  a  kind  of  genex-al  desolation  ;  the  earth  trembled  and  moved  under  his 
feet ;  he  seemed  every  moment  in  danger  of  stepping  into  an  abyss.  He  held  bj-^ 
those  who  were  near  him,  in  order  to  prevent  them  from  stepping  into  the  chasms 
which  appeared  to  him  like  the  mouths  of  volcanoes.  He  imagined  that  the  bath- 
room was  hell,  and  tliat  the  baths  were  boats.  Tlie  blister  he  believed  was  the 
brand  of  a  galley-slave,  and  that  he  thereby  was  forever  dishonored.  The  persons 
who  surrounded  him  he  took  for  resuscitated  dead.  He  saw  his  brother  in  the 
midst  of  torments  ;  he  heard  the  cry  for  help  of  his  relations,  and  each  scream 
was  to  him  like  the  thrust  of  a  poignard.  The  crack  of  firearms  was  heard  on  all 
sides,  and  the  bullets  penetrated  his  body  ^vithout  doing  him  any  injury.  His 
mind  was  all  chaos,  confusion,  delirium.  He  could  not  distinguish  night  from 
day,  and  the  months  seemed  years.  He  blamed  himself  for  all  his  ailments,  and 
therefore  sought  to  commit  suicide.  The  more  he  suffered,  the  more  contented 
was  he,  for  he  believed  that  his  troubles  were  the  just  punishment  of  his  crimes. 
At  the  commencement  of  his  recover^-,  a  letter  which  he  received  from  his  brother 
assisted  greatly  in  bringing  him  to  a  correct  view  of  his  position.  (Baillarger, 
loc.  cit.) 

Example  XIX. — Intermiitent  vielancholy  during  the  menstrual  peHods  ;  con- 
tinued melancholia  tcith  stupor.  Recovery. — Mrs.  M  ,  set.  44,  was  admitted  into 
the  Salpetriere  on  the  24th  October,  1842.  During  the  menstrual  period,  the  pa- 
tient made  several  attempts  at  suicide  ;  her  reason  rapidly  returned,  and  by  the 
beginning  of  November  she  was  completely  well  ;  she  was  dismissed,  but  on  the 
25th  November  the  delirium  set  in  anew,  and  she  was  brought  back  to  the  hos- 
pital. During  menstruation  she  made  a  new  attempt  at  suicide.  The  patient  is 
calm,  listless,  and  sad  ;  the  countenance  stupid,  and  the  glance  unsteady.  Her 
answers  are  short  and  slowly  pronounced  ;  she  is  unable  to  collect  her  thoughts. 
to  remember  the  days  or  the  months  ;  in  short,  to  have  a  clear  idea  regarding 
anything.  Her  head  is  heavy  and  weary.  She  is  sad  without  knowing  why;  she 
believes  that  she  has  committed  many  sinful  deeds,  but  does  not  know  what  they 
are.  All  around  her  seems  changed.  She  has  ringing  of  the  ears  and  hallucina- 
tions of  hearing  ;  when  she  falls  asleep,  she  sees  shadows  and  figures ;  suddenly 
she  awakes  from  fright.  The  bowels  are  constipated,  the  appetite  good  ;  pulse 
100,  skin  cool.  Laxatives,  encouragement  to  do  some  work,  forced  promenades, 
society,  and  baths,  were  prescribed  and  followed  by  improvement. 

On  the  27th  December  the  menses  returned,  without  attempts  at  suicide  or 
aggravation  of  her  condition.  After  their  cessation  the  improvement  was  very 
rapid  ;  slie  voluntarily  engaged  in  household  work,  and  became  communicative. 

On  the  6th  January  her  reason  had  completely  returned,  and  she  communi- 
cated the  following : 

During  the  delirium  it  seemed  to  her  as  if  she  \vere  surrounded  by  fire,  which 
burned  her,  but  she  did  not  feel  the  pain  ;  she  smelt  abominable  odors,  and  her 
food  had  no  taste.  The  nights  appeared  twice  as  long  as  ordinary.  She  heard 
voices  around  her,  but  could  not  distinguish  the  words.  At  first  she  thought  that 
she  was  in  prison,  and  took  the  patients  (female)  for  disguised  men.  In  the 
morning  she  saw  the  objects  around  her  more  distinctly  than  in  the  evening. 
Just  at  the  commencement,  she  felt  persuaded  that  she  was  about  to  be  thrown 
into  a  kettle  full  of  boiling  water,  and  thought  that  she  heard  persons  putting  the 
coal  on  the  fire.  The  reason  why  she  attempted  to  commit  suicide  was  that 
everything  around  her  was  transformed,  and  that  she  herself  was  the  cause  of  it. 
She  thought  that  she  was  to  blame  for  all  the  hardsliips  and  complaints  of  the 
patients  around  her,  and  that  therefore  it  was  better  that  she  should  die.  (Bail- 
larger,  loc.  cit.) 

Section"  IV. — Melancholia  with  Destructive  Tendencies. 

§  125.  In  melancholia  this  emotional  state  of  uneasiness,  of  anxiety, 
and  especially  of  mental  suffering,  gives  rise  to  certain  im])ulses  and 
directions  of  the  Avill  which  are  manifested  in  external  actions,  which 


STATES    OF    MENTAL    DEPRESSION.  177 

always  assume  a  negative,  gloomy,  hostile  and  destructive  character. 
The  negative  ideas  and  feelings  which  here  pass  into  effort,  the  acts  which 
are  the  result  of  them,  may  be  directed  either  against  the  individual  him- 
self, against  other  persons,  or  finally  against  inanimate  objects;  and 
according  to  the  difference  of  the  outward  act,  these  cases  have  been 
described  as  different  monomanias  (monomania  of  murder,  suicide,  arson, 
etc.). 

A.  Melancholia  luith  suicidal  tendencies. — The  pathological  and  etio- 
logical history  of  suicide  does  not  appertain  entirely  to  the  province  of 
mental  medicine;  in  fact,  whatever  certain  scientific  authorities'  may 
assert,  we  are  not  warranted  in  coming  to  the  conclusion  that  suicide  is 
always  a  symptom  or  a  result  of  insanity.  There  is  no  insanity  present 
where  the  feeling  of  disgust  with  life  is  in  exact  relation  to  the  actual 
circumstances;  where  evident  moral  causes  exist  which  sufficiently  account 
for  the  act  (§  37);  where  the  resolution  has  been  deliberately  made,  and 
might  have  been  abandoned  had  the  circumstances  changed;  and  in 
which  we  discover  no  other  symptom  of  mental  derangement.  When  a 
man  of  very  delicate  feelings  puts  an  end  to  his  existence,  that  he  may  not 
survive  the  loss  of  his  honor,  or  of  some  other  highly  valued  possession 
which  forms  an  intimate  part  of  his  intellectual  being — when  a  man  pre- 
fers death  to  a  miserable,  contemptible  life,  full  of  mental  and  physical 
ills, — morality,  indeed,  may  call  him  to  account  for  the  deed,  but  there 
exists  no  ground  on  which  we  can  consider  him  insane;  the  abhorrence 
of  life  and  the  idea  of  self-annihilation  correspond  to  the  intensity  of  the 
painful  impressions  which  bear  upon  the  individual,  and  it  is  after  delib- 
erate reflection  that  the  act  is  resolved  upon  and  perpetrated.  But  the 
cases  which  come  under  this  category  are  the  rarest;  more  frequently 
the  tendency  to  commit  suicide  depends  either  upon  fully  developed 
melancholia,  with  all  its  usual  symptoms,  or  (and  this  is  more  frequent) 
on  a  state  closely  bordering  upon  melanchola  of  moderate  but,  at  the 
same  time,  general  painful  perversion  of  the  feelings.  The  apparently 
deliberate  and  cold-blooded  act  of  suicide  can,  when  considered  ;;er  se, 
no  more  prove  the  non-existence  of  insanity  than  any  other  deliberate  act 
committed  in  mental  disease.  The  disposition  to  originate  those  states  of 
mental  suffering  which  most  generally  coincide  with  exhaustion,  coldness, 
and  deadening  of  the  reaction  of  the  feelings,  is  precisely  the  same  as  the 
disposition  to  mental  diseases.  When  these  have  once  appeared,  they 
become  fixed,  and  rule  the  individual  the  more  easily  according  as  a  feeble 
ego  offers  only  slight  resistance  to  them  (p.  51);  they  therefore  frequently 
appear  as  essential  result  of  a  previously  weak  character.  They  are,  how- 
ever, essentially  distinguished  from  the  abhorrence  of  life  which  is  the 
result  of  certain  explicable  moral  causes,  by  their  internal  origin  (§  37), 
by  the  want  of  sufficient  moral  causes  to  account  for  the  act;  frequently 
by  their  evident  appearance  in  consequence  of  some  physical  disease,  by 
jiresenting  periodic  exacerbations  without  any  moral  cause;  and  finally, 

'  Esquirol  (loc.  cit.,  p.  183).  "  I  believe  that  I  have  proved  that  an  individual 
will  only  put  an  end  to  his  life  when  he  is  delirious,  and  that  suicides  are 
mentally  diseased."  Falret,  '  De  I'Hypoch.  et  du  Suicide, '  1833,  p.  137.  Esquirol, 
moreover,  expresses  himself  less  absolutely  in  other  parts  of  his  work.  Bourdin 
('  Bull,  de  la  Soc.  Med.  Prat,  de  Paris,'  1845,  No.  41,  p.  38)  has  attempted  in  an 
elaborate  essay  to  prove  the  theory  that  every  suicide  is  a  monomaniac.  Brierre 
has  recently  opposed  the  opinion  of  the  universally  morbid  nature  of  suicide,  etc. , 
by  the  interesting  collection  of  the  last  writings  of  very  many  suicides,  and 
called  attention  to  the  ordinary  clearness  and  deliberateness  which  these  writings 
showed. 

12 


178  STATES    OF    MENTAL    DEPRESSION. 

by  being  sometimes  undoubtedly  hereditary.  When  the  whole  psychical 
life  is  governed  by  this  perversion  of  the  feelings,  there  arise  no  limiting 
or  restricting  ideas  and  impulses  to  resist  the  thought,'  be  it  spontaneous 
or  suggested,  of  self-destruction;  or  these  ideas  and  impulses  soon  become 
worn  out  and  exhausted,  owing  to  the  existence  of  those  which  constantly, 
and  with  the  persevering  obstinacy  of  all  other  melancholic  dispositions 
of  this  kind,  urge  themselves  upon  the  ego.  Indeed,  the  more  insignifi- 
cant the  outward  motives  to  the  deed,  the  more  likely  are  we  to  find  in 
the  antecedent  history  of  the  individual,  causes,  or  even  certain  symp- 
toms, of  incipient  insanity;  and  the  more  barbarous  and  the  more  extra- 
ordinary the  means  employed  for  the  perpetration  of  the  deed,*  the  more 
are  we  warranted  in  considering  it  to  be  a  result  of  some  morbid  perver- 
sion of  the  faculties. 

Sometimes  we  see  in  persons  hitherto  healthy  a  suicidal  impulse  sud- 
denly developed,  as  a  form  of  raptus  melancholicus,  with  obscuring  of 
the  consciousness  and  all  the  signs  of  great  exaltation.  (Example  XX.) 
Thus  in  the  case  recorded  by  Forbes  Winslow,  a  lady  in  whom  no  one 
had  ever  remarked  anything  extraordinary,  suddenly  during  dinner  sprang 
up  and  attempted  to  throw  herself  over  the  window;  she  was  prevented 
accomplishing  her  purpose,  and  forthwith  there  was  developed  an  attack  of 
mania.  If  the  suicide  has  been  successful,  it  would  have  represented  a 
case  of  very  problematical  raptus  occurring  in  a  healthy  person.  In 
many  of  those  cases  in  which  the  individual  suddenly  resolves  to  put  an 
end  to  his  existence,  and  immediately  puts  his  purpose  into  execution, 
and  where  we  have  failed  to  recognize  the  existence  of  any  characteristic 
delirium,  if  we  attentively  examine  the  facts,  we  shall  probably  find  that 
for  a  long  time  past  the  individual  has  been  plunged  in  the  most  pro- 
found hypochondria;  that  he  has  constantly  been  dwelling  upon  the  state 
of  his  health;  that  he  has  frequently  complained  of  being  unable  to  com- 
mand his  thoughts  and  will  as  formerly;  that  he  has  been  annoyed  with 
a  general  weakness,  accompanied  by  vague  systems  of  bodily  discomfort, 
particularly  with  derangement  of  the  digestive  functions.  The  weariness 
of  life  is  generally  more  chronic,  which  shows  itself  as  spleen  owing  to 
weakness  of  the  constitution  from  hard  drinking — that  general  exhaus- 
tion and  desolution  of  mind  which  arises  from  various  causes,  and  among 
others  from  immorality,  onanism,  and  venereal  excesses;  sometimes  it 
almost  appears  as  if  some  slight  deviations  in  the  development  of  the  sex- 
ual organs  might  give  rise  not  only  to  those  longing  hypochondriac  states 
of  mind  which  we  often  enough  see  at  the  period  of  puberty,  but  might 
also,  in  some  individuals,  awaken  suicidal  impulses. 

Cases  of  suicide  occur  at  all  ages  of  life,  even  among  mere  children. 
We  have  already  seen  (§  92)  that  it  is  frequently  hereditary,  and  that  it 
may  alternate  with  other  forms  of  insanity  in  different  generations.  It 
is  about  three  times  more  frequent  among  males  than  females.  The  most 
recent  and  reliable  statistics  would  seem  to  indicate  that  it  is  increasing 
in  frequency  at  a  most  astounding  and,  so  to  speak,  progressive  rate.  In 
Berlin,  Caspar  has  demonstrated  the  correctness  of  this  statement.  In 
France,  the  statistics  of  the  minister  of  justice  show,  during  a  period  of 
ten  years,  from  1827  to  1837,  the  astonishing  increase  of  about  one  fourth;* 
from  1838  to  1852,  the  increase  still  continued;  in  1838  and  1839,  there 

'  Imitation  of  suicide. 

^  See  the  shocking  case  of  starvation  in  '  Hufeland's  Journal,'  1819;  the  case  of 
Matthieu  Lovat,  who  crucified  himself,  etc. 

3  Dufan,  '  Traite  de  Statistique,'  Paris,  1840,  p.  298. 


STATES    OF    MENTAL    DEPRESSION.  179 

occurred  one  case  of  suicide  in  every  12,489  inhabitants;  and  in  1852,  one 
in  every  9340  (Lisle):  in  1827  the  proportion  was  only  as  1  to  every  20,660 
inhabitants;  and  in  1836  it  stood  as  1  to  every  14,338.  It  is  well  known 
that  suicide  is  often  propagated  by  imitation;  examples  of  this  kind  are 
numerous,  from  the  case  of  the  maidens  of  Mileta,  of  whom  Plutarch 
Avrote,  to  that  of  the  well-known  example  in  the  Invalides  in  Paris,  and 
others  of  still  more  recent  date.  In  all  times,  too,  cases  have  not  been 
wanting  where  two  individals  of  different  sex  have  together  committed 
suicide,  and  those  in  which  the  person  put  an  end  to  his  existence  after 
having  committed  some  act  of  violence. 

It  is  not  our  intention  to  enter  into  details  regarding  the  causes  and  social  sig- 
nificance of  suicide,  or  to  enumerate  tlie  statistics  of  different  countries  in  regard 
to  it.  As  to  the  latter,  and  the  hundreds  of  documents  which  are  brought 
forward  to  prove,  what  we  have  already  admitted,  viz.  the  enormous  increase  in 
the  numljer  of  cases  of  suicide  in  our  time,  their  authority  is  of  precisely  the 
same  value  as  that  of  the  statement  regarding  the  great  increase  of  insanity 
(g  85).  The  older  statistics  were  both  inaccurate  and  defective,  and  it  is  just 
possible  that  the  increase  which  it  has  been  attempted  to  establish  may  only  be 
apparent;  the  later  statistics  being  much  more  exact  and  complete.  Thus,  as  I 
have  mentioned  in  the  first  edition  of  this  work,  M.  Archambault  assured  us  in 
1843,  that  so  far  at  least  as  France  was  concerned,  this  increase  in  the  number  of 
suicides  was  not  an  actual  fact  ('Ann.  Med.  Psych.,'  i.,  p.  147),  and  that  the  dif- 
ference was  entirely  due  to  the  much  greater  care  and  exactitude  with  which  the 
statistics  were  drawn  up.  This  is  possible,  just  as  it  is  in  regard  to  insanity  in 
general  (§  85),  but  not  at  all  probable;  it  must  be  admitted  that  there  is  an  actual 
increase  in  the  number  of  suicides,  but  the  rate  of  progression  is  not  so  great  as 
has  been  mentioned. 

Solomon  ('Welches  sind  die  Ursachen,'  etc.,  Bromberg,  1861)  has,  moreover, 
pubhshed  some  extremely  interesting  statistical  tables,  from  which  it  comes  out 
that  the  number  of  suicides  in  Belgium  from  1846  to  1855,  in  Sweden,  and  even  in 
Paris,  so  far  from  increasing  in  a  constant  uniform  progression,  is  maintained 
within  certain,  not  very  extended  limits.  In  the  central  European  countries,  it 
is  reckoned  that  at  tlie  present  day  there  occurs,  on  an  average,  one  suicide  in 
every  12  or  15,000  inhabitants:  in  the  East,  suicide  was  and  still  is  rare.  At  least 
one -fifth,  perhaps  one-fourth,  of  those  who  commit  suicide  are  drunkards.  In 
France,  the  greater  part  adopt  drowning  as  the  means  of  ending  their  existence; 
while  in  England  and  Germany,  hanging  is  the  favorite  method.  One  very 
mournful  fact  connected  with  this  subject  is  the  suicide  of  children.  In  England, 
during  the  space  of  five  years,  from  1852  to  1856,  out  of  5415  cases  of  suicide,  33 
were  committed  by  children  under  the  age  of  ten  yeai-s  (Buckle).  Durand-Fardel 
('Ann.  Med.  Psych.,'  1855)  has  collected  twenty-six  cases  of  suicide  by  persons 
varying  in  age  from  five  to  fourteen  years.  The  motives  which  usually  lead  to 
this  mournful  end  are,  as  a  rule,  pitiable  as  compared  with  those  in  adults;  fear 
of  punishment,  etc.  Thus,  a  boy,  aged  nine  years,  killed  himself  because  he  had 
lost  a  bird;  another,  aged  eleven  years,  whose  case  Schlager  describes,  from  dis- 
appointed love;  another,  aged  five,  threw  himself  into  the  water  because  his 
mother  maltreated  him.  It  is  a  fact  that  death  does  not  inspire  children  with  the 
same  fear  as  it  does  in  the  majority  of  adults,  and  the  weak  ego  is  easily  over- 
come by  the  idea  of  the  thing.  Further,  in  such  children  there  has  often,  for  a 
long  time,  been  observed  something  anomalous,  a  certain  perversion  of  the 
feelings;  as,  for  example,  cruelty  to  animals  (for  examples,  see  Forbes  Winslow, 
"Obscure  Diseases  of  the  Mind  and  Brain,"  London,  1859,  p.  186), 

§  126.  We  must  carefully  distinguish  (with  Guislain'),  among  the 
actually  insane,  those  cases  in  which  the  suicidal  impulse  is  the  most 
essential  symptom  of  the  malady,  the  chief  disease,  from  those  in  which 
it  appears,  merely  as  an  epiphenomenon,  during  the  course  of  some  other 
form  of  mental  affection.  The  majority  of  insane  persons  in  whom  this 
suicidal  impulse  manifests  itself  suffer  from  some  well-pronounced  form 

'  '  Lemons  orales,'  i.,  p.  244. 


180         .  STATJiS    OF    MENTAL    DEPRESSION 

of  melancliolia.  But  the  psychological  motive  which  gives  rise  to  this 
impulse  is  far  from  being  uniform.  Often  it  is  an  insupportable  excess 
of  a  general  nndefined  feeling  of  anxiety  which  leads  the  patient  to  seek 
relief  in  suicide;  at  other  times  he  gives  way  to  this  impulse,  because  he 
feels  that  all  his  feelings  have  become  disagreeable  and  frightful,  and  his 
mind  subject  to  dreary  and  wicked  ideas;  in  desperation  concerning  this 
perpetual  yoke,  he  considers  himself  unworthy  longer  to  live,  and  imag- 
ines his  whole  life  is  evil,  abandoned,  and  impious.  Or  there  arise  dismal 
ideas  of  general  non-existence;  the  sufferer  imagines  that  the  whole  world 
is  annihilated,  and  that  consequently  he  too  must  put  an  end  to  his  ex- 
istence. But  that  which  is  perhaps  the  most  frequent  occurrence  is  the 
presence  of  hallucinations,  in  which  the  profound  uneasiness  of  the  feel- 
ings, and  the  still  more  dismal  ideas  of  self-destruction,  take  a  sensible 
form,  and  are  presented  to  the  mind  of  the  patient  with  all  the  force  and 
reality  of  objective  perceptions  (voices  which  say,  ''Slay  thyself  !  Slay 
thyself  !"  or  hallucinations  of  vision  conveying  the  direct  commands  of 
the  Deity).  Such  impulses  come  in  melancholies  often  very  suddenly 
and  transiently  (lasting  some  hours  or  days) ;  sometimes  there  appears 
with  the  accomplishment  of  the  deed,  even  though  unsuccesful,  an  actual 
relief  and  remission,  just  as  in  other  cases  we  observe,  after  some  injury 
or  act  of  violence  has  been  perpetrated  on  another  person  by  one  of 
unsound  mind,  that  the  feeling  of  profound  oppression  which  weighed 
so  heavily  on  the  patient  is  thereby  removed,  and  perfect  calm  is  restored. 
Many  melancholies  artfully  seize  an  opportune  moment  to  put  into  exe- 
cution the  resolution  long  ago  taken,  but  till  now  concealed ;  at  other 
times  they  openly,  one  might  almost  say  shamelessly,  avow  their  purpose 
to  commit  suicide,  and  diligently  await  for  weeks  and  months  an  oppor- 
tunity of  satisfying  this  impulse  by  every  possible  means,  and  even  before 
the  very  eyes  of  their  attendants. 

Schlager  (Prager  '  Vierteljahrsschr.,'  Bd,  64,  1859,  p.  1)  observed  that  in  1000 
cases  of  insanity,  91  who  either  committed  suicide,  or  made  the  attempt  to  do  so, 
almost  all  were  melanchohcs.  In  these  cases  the  most  important  predisposing 
causes  were,  cerebral  congestions,  profound  exhaustion  caused  by  previous  dis- 
ease, disappointed  love,  drunkenness  conjoined  with  mental  excitement  (here  we 
often  see  a  suicidal  impulse  suddenly  develop  itself,  and  if  the  commission  of  the 
deed  be  prevented,  the  patient  retains  no  recollection  of  what  has  taken  place);  in 
one  solitary  case  fear  was  the  determining  cause.  Exhaustion  of  the  constitution, 
anaemia,  a  chronic  cerebral  hypera^mia,  dysmenorrhoea,  chlorosis,  the  climacteric 
period,  and  diseases  of  the  heart,  were  also  observed  to  have  considerable  influ- 
ence in  producing  this  state  of  mind.  The  mode  of  death  which  these  individuals 
chiefly  selected  was  hanging. 

But  it  is  not  only  in  melancholia  that  we  observe  this  suicidal  ten- 
dency ;  we  meet  with  it  also  in  other  forms  of  mental  disease.  It  then 
depends,  not  so  much  on  abhorrence  of  life,  as  upon  all  kinds  of  delirious 
conceptions,  in  the  more  restricted  sense  of  the  term;  the  idea,  for 
example,  of  martyrdom  for  the  benefit  of  mankind,  of  being  about  to 
enter  paradise,  which  is  presented  to  their  eyes  in  splendid  visions,  etc. 
Further,  there  occasionally  appear,  in  persons  suffering  under  partial 
dementia,  intercurrent  attacks  of  suicidal  impulse,  from  most  intense 
abhorrence  of  life,  as  a  form  of  melancholic  or  maniacal  raptus.  In  the 
asylum  at  Winnenthal,  there  was,  for  many  years,  a  mentally  weak  and 
partially  demented  patient  (ideas  of  being  the  Emperor  of  China,  etc  ),  who 
from  time  to  time  was  suddenly  (with  considerable  cerebral  congestion) 
seized  with  the  most  intense  disgust  of  life,  and  it  was  only  by  being  con- 
tinually kept  under  restraint  that  he  was  prevented  from  putting  into 


STATES    OF    MENTAL    DEPRESSION.  181 

execution  his  determination  to  commit  suicide.  These  attacks  lasted  for 
live  or  six  days,  and  then  completely  disappeared  ;  on  each  occasion  the 
withdrawal  of  some  blood  from  the  head  seemed  essentially  to  aid  in  cut- 
ting short  and  diminishing  the  strength  of  the  fit.  Those  cases  in  which 
the  insane  kill  themselves  unintentionally  and  without  wishing  to  die  are 
to  be  distinguished  from  cases  of  suicide  ; — when,  for  example,  a  maniac 
in  the  midst  of  his  delirium  mistakes  the  window  for  the  door,  and  insists 
upon  making  his  exit  by  that  means,  or  when  he  leaps  out  at  the  window 
in  obedience  to  the  command  of  the  Almighty,  whose  voice  he  hears  say- 
ing, '*  Gro  to  the  window,  and  thou  shalt  fly  as  doth  a  bird  ;"*  or  when  a 
monomaniac  believes  that  he  is  commissioned  to  convert  mankind,  and  in 
order  to  convince  people  that  he  is  really  sent  from  God,  and  therefore 
invulnerable,  throws  himself  from  a  bridge  and  is  drowned;' — these  are 
not  cases  of  suicide,  for  here  the  patients  had  no  desire  to  kill  themselves. 
Closely  allied  to  such  cases  of  morbid  self-destruction,  and  falling  under 
the  same  category,  are  those  examples  of  self-mutilation,  generally  the 
result  of  melancholia  or  delirious  ideas,  in  which  the  patients  cut  off  their 
fingers,  tear  out  their  eyes,  cut  off  their  testicles,  etc.  At  times  we  are 
warranted  in  coming  to  the  conclusion  that  there  is  in  these  parts  a 
considerable  diminution  of  the  sensibility. 

Cases  also  occur  in  which  persons  actually  insane  simulate  attempts  at  suicide; 
it  does  not,  however,  follow  that  the  mental  disease  is  simulated.  Morel,  '  Ann. 
Med.  Psychol.,'  vi.,  1854,  p.  84,  mentions  a  case  of  this  description. 

Example  XX. — Sudden  appearance  of  attempts  at  suicide  ivith  obscuring  of  the 
consciousness  and  loss  of  alt  recollection  — A  lady  still  alive,  and  now  (1821)  43 
years  of  age,  had  hitherto  lived  in  comfortable  circumstances,  and,  excepting 
occasional  hysteric  headaches  and  dj'smenorrhcea,  in  the  constant  enjoyment  of 
good  health.  Up  to  the  year  1804,  she  had  never  met  with  a  misfortune.  Her 
husband  loved  her  tenderly;  her  children,  whom  she  herself  had  partly  nursed, 
were  strong  and  healthy,  and  her  circumstances  easy.  On  the  24th  July  of  this 
year,  however,  after  she  had  suffered  for  several  days  before  from  her  ordinary 
headache,  but  which  by  this  time  had  disappeared,'she  was  sitting,  at  half -past  three 
o'clock  after  noon,  in  her  own  house,  apparently  well  pleased  and  engaged  in  knit- 
ting. Suddenly,  and  without  the  least  provocation,  she  sprung  up  and  called  out, 
' '  I  must  drown  myself — I  must  drown  myself ! "  whereupon  she  ran  straight  to  the 
moat  which  surrounded  the  town,  and  threw  herself  into  it.  She  was  immedi- 
ately taken  out  of  the  water  and  carried,  apparently  dead,  to  her  home.  A  doctor 
was  rapidly  summoned,  and  he  speedily  restored  animation.  She,  however,  re- 
mained mute,  and  stared  with  widely  open  eyes  fixedly  on  one  spot,  paying  no 
attention  to  the  events  which  passed  around  her.  I  saw  her  for  the  first  time  on 
the  evening  of  the  27th  of  July.  She  had,  it  is  tiiie,  during  the  time  which  had 
intervened  since  the  attack,  calmly  submitted  to  all  that  was  done  to  her,  and 
even  swallowed  some  medicine;  but  she  had  not  spoken,  nor  partaken  of  food  or 
drink — she  had  not  slept,  nor  shown  interest  in  anything.  When  I  saw  her  late 
at  night,  she  was  lying  in  bed,  and  sighed  continually.  When  I  spoke  to  her,  she 
started  and  pronounced  my  name.  A  candle  was  brought,  and  when  she  saw  me 
she  exclaimed,  "My  God!  where  am  I,  and  what  has  happened  to  me?"  and 
commenced  to  weep  violently.  I  soon  calmed  her.  After  she  had  recognized 
and  spoken  to  her  husband,  and  inquired  about  her  children,  she  fell  asleep  and 
rested  undisturbed  till  morning. 

On  awaking,  she  at  once  cheerfully  inquired  about  all  that  had  happened,  and 
was  astonished  to  hear  of  her  attempt  to  drown  herself,  and  of  the  danger  into 
which  she  had  thereby  fallen.  On  my  appearance  next  morning,  she  laughingly 
asked  what  I  actually  thought  and  had  said  of  her,  and  was  anxious  to  know  how 
she  could  have  come  to  the  foolish  idea  of  drowning  herself  without  being  con- 
scious of  the  occurrence  or  knowing  any  cause  for  it.  Since  then  she  has  had 
several  children,  and  many  things  have  occurred  to  disturb  her  equanimity,  but 
she  has  never  had  any  such  extravagant  ideas.     With  the  exception  of  occasional 

'  Leuret,  'Fragments,'  p.  290. 

2  Falret,  '  Hypoc.  et  Suic,"  p.  139. 


182  STATES    OF    MENTAL    DEPRESSION. 

hysterical  attacks  and  dysmenorrhoea,  she  has  always  continued  healthy,  cheer- 
ful, and  gay.     (Mende,  in  Henke,  '  Zeitschrift  fiir  die  Staatsarzneikunde,'  1821.) 

Example  XXI. — Tendency  to  suicide  caused  by  concealed  hallvAiinations. — A 
young  man  of  large  fortune  had  been  addicted  to  onanism,  but  nevertheless  con- 
tinued to  enjoy  pretty  good  health.  He  had  no  other  cause  of  annoyance  than  the 
remembrance  of  the  Revolution,  the  principles  of  which  he  disapproved  of,  and 
had  even  on  several  occasions  attempted  to  commit  suicide  by  shooting  himself 
with  a  pistol,  and  would  use  no  other  means.  He  remained  for  two  years  under 
my  care,  during  which  time  he  did  not  speak  one  word  of  nonsense;  he  was 
cheerful,  amiable,  well-informed,  and  jometimes  said  to  me,  "Give  me  a  pistol !" 
— "Why  would  you  kill  yourself  ?  " — "  Because  all  seems  tiresome."  It  was  not 
till  after  the  lapse  of  two  years  tliat  he  informed  me  that  for  a  long  time  he  had  been 
subject  to  hallucinations  of  hearing  and  of  sight.  He  believed  that  he  was  fol- 
lowed by  policemen,  whom  he  constpjitly  heard  and  saw,  even  between  the  walls 
of  his  apartment,  which  he  believed  were  double,  and  consisted  of  two  movable 
partitions,  so  that  one  could  hear  and  see  all  which  he  said  or  did.  (Esquirol, 
'Maladies  Mentales,'  i.,  p.  555.) 

Example  "KXll.  — Vague  impulse  to  commit  suicide  caused  by  a  violent  fright 
during  a  state  of  bodily  weakness. — N — ,  a  tailor,  set.  31,  had  fallen  into  a  state  of 
great  exhaustion  in  consequence  of  onanism,  and  had  afterwards  to  submit  to 
repeated  courses  of  treatment  by  mercury.  On  the  outbreak  of  cholera  in  the 
year  1831,  he  was  so  terrified  by  the  report  that  the  patients  were  drawn  from 
their  dwellings  with  tongs,  and  otherwise  roughly  handled,  that  he  fell  into  a 
swoon  and  believed  that  he  was  seized  with  cholera.  At  first  he  could  not  work 
during  the  day,  nor  sleep  at  night,  and  the  idea  that  he  also  must  subject  himself 
to  treatment  so  frightful  set  him  quite  beside  himself.  He  even  spent  the  night 
with  friends  for  fear  of  being  carried  off  to  a  cholera  hospital.  When  at  work, 
his  limbs  trembled  from  anxiety:  this  he  considered  to  be  a  premonition  of  chol- 
era, having  heard  that  fright  predisposed  to  it.  His  appetite  left  him,  and  besides 
he  was  afraid  to  eat  too  much,  as  too  much  food  and  many  kinds  of  it  seemed 
hurtful  to  him;  indeed,  he  weakened  his  digestion  through  abstinence.  Being 
perpetually  tormented  by  fears,  he  slept  little,  and  dreamed  a  great  deal  of  deaths 
and  funerals.  During  the  day  he  could  not  venture  out,  for  fear  of  the  disease 
and  of  the  police.  This  torment  threw  him  into  a  state  of  mind  so  irritable,  that 
the  sight  of  cattle  going  to  the  slaughter-house  disturbed  him  very  much,  because 
he  represented  to  himself  how  the  knife  would  be  plunged  into  then*  throats.  At 
last,  when  he  had  somewhat  recovered  from  this  anxiety,  he  one  day  heard  a  sliot 
go  off;  whereupon  he  became  very  much  afraid,  because  he  thought  that  some 
one  had  committed  suicide.  On  the  same  evening  he  learned  that  a  person  in  the 
neighborhood  had  cut  his  throat.  His  terror  was  now  so  great  that  he  could  not 
sleep  at  night,  because  he  kept  constantly  considering  how  the  suicide  had  com- 
mitted the  deed — what  part  of  his  body  had  he  wounded?  In  vain  he  attempted 
to  banish  these  thoughts,  which  were  continually  arising  anew  on  the  slightest 
occasion;  forexample,  by  a  headless  figure  in  the  Royal  Museum,  which  represented 
in  his  eyes  a  beheaded  individual.  If  a  knife  lay  before  him,  it  seemed  to  him  as 
if  he  must  cut  his  throat,  in  spite  of  his  horror  of  it  and  his  love  of  life.  When  a 
knife  was  put  into  his  hand,  he  trembled  and  threw  it  from  him,  or  laid  it  under 
his  plate  that  he  might  not  see  it.  He  constantly  ':hought  of  violent  modes  of 
death:  if  he  saw  a  rope,  the  idea  of  haiiging  immediately  entered  his  mind;  if  he 
crossed  a  bridge,  he  felt  as  if  he  must  jump  into  ':he  water — therefore  he  never 
walked  near  the  edge,  but  rapidly  ran  across  in  the  centre  of  the  bridge,  in  order 
not  to  be  impelled  to  throw  himself  over  against  his  will,  if  he  stood  at  a  window, 
he  felt  impelled  to  jump  through  it,  and  therefore  retreated  in  terror.  Knives 
and  pistols  were  presented  to  him,  that  he  might  become  accustomed  to  handle 
them;  but  he  could  not  command  himself  for  fear„  After  this  terror  had  long 
pursued  him,  and  had  at  last  attained  to  its  highest  degree,  he  voluntarily  sought 
admission  into  the  Charite.  Here  even  this  condition  lasted  for  a  considerable 
length  of  time,  but  at  last  complete  recovery  took  place  under  the  employment 
of  continuous  bodily  exercise  and  the  use  of  baths.  (Marc,  translated  by  Ideler, 
i.,p.  196.) 

Example  XXIII. — Suicide  caused  by  anxiety  and  hallucinations. — A  former 
soldier,  set.  38,  received  fracture  of  both  legs,  which  were  accordingly  amputated. 
He  became  dull,  and  was  seized  with  an  attack  of  mania.  He  heard  voices  which 
continually  insulted  him,  persecuted  him,  and  threatened  to  shoot  him.  These 
were  followed  by  answers  which  he  directed  to  the  voices.  The  state  of  hallur  i- 
nations  and  anxiety  lasted  for  tuu  months,  in  spite  of  all  possible  remedies.     Tu(» 


STATES    OF    MENTAL    DEPRESSION.  183 

patient  became  always  more  absorbed  in  his  false  sensations  ;  he  persistently 
refused  food  in  order  to  tvithdraw  himself  from  these  torments^-the  voices  demand 
that  he  should  eat  no  more.  He  had  to  be  fed  by  force  ;  the  more  feeble  he 
became,  the  stronger  the  voices  seemed  to  become  :  at  last  he  died  from  exhaus- 
tion.    (So.  Pinel,  'Pathol.  Cerebr.,'  Par.,  1844,  p.  212.) 

Example  XXIV. — I  have  at  present  under  treatment  a  young  girl  who  has  pro- 
lapsus of  the  uterus,  caused  by  a  violent  blow  on  the  os  sacrum.  Since  the  acci- 
dent she  suddenly  becomes  very  low-spirited,  and  suffers  from  a  most  peculiar 
perversion  of  ideas,  and  a  tendency  to  suicide  whenever,  from  any  exertion,  the 
neck  of  the  uterus  presents  itself  at  the  orifice  of  the  vagina  or  passes  through  it. 
This  remarkable  anomaly  is  prevented  by  the  employment  of  a  pessary.  (Guis- 
lain,  '  Plirenopathies,'  1838,  p.  282.) 

B. — Melancholia  ivith  Destructive  and  Murderous  Tendencies. 

§  127.  Directly  and  immediately  connected  with  the  suicidal  impulse, 
is  the  morbid  tendency  to  injure  and  destroy  other  persons  or  inanimate 
objects.  Not  only  do  these  tendencies  frequently  occur  together — not 
only  have  these  acts  of  violence  towards  others,  inasmuch  as  they  are 
often  perpetrated  upon  those  most  loved  and  cherished  by  the  patient,  fun- 
damentally the  same  essential  character  as  the  tendency  to  self-injury 
and  self-mutilation — but,  in  general,  both  depend  upon  the  same  funda- 
mental state  of  morbid  negative  emotion,  and  in  both  there  may  be  also 
observed  certain  differences  in  the  immediate  morbid  cause. 

As  to  the  psychical  motives  which  give  rise  to  these  acts  of  violence 
in  persons  already  laboring  under  melancholia,  these  impulses  would 
seem  to  be  due,  in  part  at  least,  to  an  actual  delirium  of  the  intelligence 
or  of  the  sensorial  perception.  To  this  class  belong  those  cases  in  which 
the  patients  imagine  that  they  are  persecuted,  or  generally  injured  by 
others,' — where  they  attribute  to  certain  persons  insulting  and  injurious 
expressions  which  they  hear  of  their  hallucinations  of  hearing,  and  con- 
sequently actually  commit  deeds  of  vengeance  upon  them.  To  these  are 
very  closely  associated  those  violent  deeds  which  are  suggested  under  the 
idea,  evidently  melancholic,  that  everything  in  this  world  is  bad,  that 
everything  is  abandoned  and  lost;  that,  for  example,  the  innocent  chil- 
dren may  be  best  delivered  from  the  misery  of  this  world  by  an  early  (vio- 
lent) death;  or  the  patient,  without  the  slightest  ground  for  any  such 
fear,  imagines  that  there  is  now  left  to  him  no  possible  means  of  existence, 
and  that  soon  he  will  perish  of  hunger  and  misery,  etc.  These  ideas,  more 
or  less  obscure,  not  unfrequently  discover  themselves  in  hallucinations, 
in  which  the  patient  is  directly  commanded  to  kill,  it  may  be  children  or 
wife;  and  falling  under  nearly  the  same  category,  are  those  hallucinations 
of  hearing  which  partake  of  religious  fanaticism  (voice  of  God  or  of 
angels),  in  which  the  patient  hears  the  command  to  go  and  follow  the 
example  of  Abraham,  and  such  like.  Such  acts  spring  from  vague  ideas 
of  the  necessity  of  sacrificing  some  person,  other  than  but  closely  con- 
nected with  the  patient,  an  expiation  of  some  terrible  but  imaginary 
crime;  while  in  other  cases  the  patient,  regarding  himself  as  a  felon  shun- 
ned by  all,  commits  some  dreadful  deed  in  order  to  draw  down  upon 
himself  the  well-deserved  punishment  of  death. 

In  regard  to  a  great  many  of  these  cases,  including  those  which  be- 
long to  the  following  paragraph,  there  is  a  most  important  and  charac- 

'  Thus,  for  example,  the  cases  which  have  several  times  occurred  of  patients 
attempting  to  murder  their  physicians.  See  Marc,  translated  by  Ideler,  ii.,  p.  'J. 
We  would  refer  generally  to  the  rich  collection  of  cases  contained  in  this  work  to 
illustrate  this  chapter. 


184  STATES    OF    MENTAL    DEPKESSION. 

teristic  circumstauce  which  we  have  ah-eady  adverted  to  in  speaking  of 
suicide,  viz.,  the  freeing  of  the  patient  from  his  painful  emotions  and 
frightful  thoughts  by  the  fact  that  the  deed  committed  has  become  ob- 
jective to  him;  the  ease  and  calm  wliich  the  patie.nt  gains  by  the  mani- 
festation of  his  disposition,  by  the  accomplishment  of  the  deed — a  cir- 
cumstance which  gives  to  these  acts  what  has  been  termed  a  critical 
significance.  In  the  following  very  simple  cases,  there  may  be  recog- 
nized various  modifications  of  such  mental  disburdening;  something  sim- 
ilar is  frequently  observed  after  the  actual  accomplishment  of  deeds  of 
murder  depending  on  melancholic  motives. 

Example  XXV. — A  case  of  melancholia  presented  a  character  which  is  not 
uncommon,  and  which  in  its  higher  degrees,  and  when  it  has  attained  its  full 
development,  represents  a  form  of  "moral  insanity."  The  patient,  a  married 
lady,  aged  45,  fell  into  a  state  of  profound  melancholia,  with  constant  anxiety. 
She  declared  that  whenever  she  heard  or  read  of  a  crime,  she  felt  an  intense 
desire  to  commit  the  same  crime,  but  at  the  same  time  she  also  felt  a  very  great 
terror  of  its  accomplishment.  It  was  impossible  for  her  to  recount  all  the  terrible 
things  which  passed  through  her  mind.  She  added  that  every  act  of  violence, 
whether  in  word  or  deed,  which  she  perpetrated  on  her  children  or  those  around 
her,  afforded  her  considerable  relief,  and  that  she  had  now  the  greatest  difficulty 
in  controlling  herself. 

The  patient  recovered  under  the  employment  of  dilute  acids,  tincture  of 
opium,  digitalis,  infusion  of  quassia,  and  laxatives.  (Guy,  "King's  College 
Annual  Reports,"  1841  ;  'Lond.  Med.  Gaz.,'  Sept.,  1842.) 

Example  XXVI. — A  patient  who  suffered  from  fissure  of  the  anus  and  sperma- 
torrhoea, with  transitory  cerebral  congestion,  gradually  fell  into  melancholia.  He 
abominated  suicide,  but  an  evil  genius  seemed  constantly  to  urge  him  to  it.  The 
sight  of  anything  with  a  sharp  point,  or  of  firearms,  caused  him  to  tremble,  and 
awakened  in  him  an  impulse  to  kill  himself,  from  which  he  could  only  free  him- 
self by  exciting  violent  pain  ;  for  example,  by  severely  pinching  some  part  of  his 
body.  He  rudely  repelled  the  kind  ofiices  of  his  friends.  He  detested  what  was 
bad,  but  felt  himself  involuntarily  impelled  to  commit  evil  deeds:  thus  he  expe- 
rienced pleasure  in  tormenting  a  lady  whom  he  loved  very  much,  and  then  seeing 
her  weep.    (Lallemaud,  '  Des  Pertes  seminales,'  i.,  p.  251.) 

§  128.  We  frequently  see  in  subjects  who,  up  to  that  moment,  have 
been  in  the  actual,  or  at  least  apparent,  enjoyment  of  perfect  health, 
just  as  in  some  of  those  cases  in  which  there  is  developed  a  suicidal  ten- 
dency (No.  XX.),  attacks  of  most  violent  anxiety  with  obscuring  of  con- 
sciousness suddenly  show  themselves;  accompanied  with  frightful  hallu- 
cinations, during  which  the  patient,  in  the  blindness  of  his  fury,  seeks  to 
massacre  and  slay  all  who  come  in  his  way.  These  cases,  which,  judged 
by  their  symptoms,  appertain  more,  it  is  true,  to  mania,  but  which,  in 
their  psychological  relations,  represent  violent  fits  of  melancholic  anxiety, 
and  especially  morbid  negative  emotions,  possess,  in  their  want  of  any 
actual  moral  cause,  a  great  analogy  to  those  sudden  fits  of  profound 
anxiety  and  severe  mental  suffering  which  have  sometimes  been  witnessed 
as  precursors  of  ^^iV^'^^^'c attacks.' 

Almost  as  obscure,  in  so  far  as  the  motives  which  dictate  them  are  con- 
cerned, and  yet  of  the  greatest  importance  in  a  medico-legal  point  of  view, 
are  those  cases  where  individuals  hitherto  perfectly  sane  and  in  the  full 
posession  of  their  intellects,  are  suddenly,  and  without  any  assignable 
cause,  seized  with  the  most  anxious  and  painful  emotions,  and  with  a 
homicidal  impulse  as  inexplicable  to  themselves  as  to  others.  In  such 
cases  there  are  two  categories  into  which  they  must  be  carefully  arranged 
and  distmguished. 

^  See  the  chapter  on  epilepsy. 


STATES    OF    MENTAL    DEPRESSION.  185 

Under  the  first  fall  those  cases  in  which  those  homicidal  impulses, 
suddenly  and  without  external  motive,  arise  in  persons  Avho  have  been 
hitherto  of  a  lively,  joyous,  and  loving  disposition,  and  incessantly  in- 
trude themselves  upon  their  thoughts.  Most  generally,  there  arises  a 
profound  and  mournful  division  of  the  consciousness,  an  internal  strug- 
gle and  storm  of  the  most  painful  nature  with  these  new  and  fearful 
ideas,  against  which  the  whole  former  contents  of  the  /  resist  with  all 
their  power,  which  of  course  varies  in  different  individuals.  Frequently, 
during  the  combat,  the  individual  is  only  able  to  prevent  the  total  dis- 
comfiture and  defeat  of  the  /  by  retiring  from  the  struggle  and  betaking 
himself  to  a  solitary  neighborhood,  where  the  impulse  which  thus  be- 
sets him  no  longer  finds  an  object.  Then,  after  a  certain  time,  these 
thoughts  may  again  disappear  as  quickly  as  they  sprang  into  existence, 
and  the  individual  is  again  as  he  used  to  be.  He  scarcely  knows  how  he 
fell  into  this  painful,  terrible  dream,  and  with  a  feeling  of  intense  relief 
he  breathes  again  with  the  knowledge  that  it  has  terminated  so  happily. 
At  other  times,  hoAvever — and  fortunately  this  is  rarer — the  /  is  compelled 
to  succumb,  and  the  unfortunate  one  perpetrates  the  deed,  and  that  too 
without  affording  him  any  advantage,  with  the  certain  prospect  of  a  life 
of  shame  and  misery — indeed,  with  tlie  certain  expectation  of  the  dis- 
graceful death  which  the  last  penalty  of  the  law  inflicts.  This,  however, 
appears  to  him  as  a  relief,  and  an  actual  benefit,  as  compared  with  the 
perpetual  anxiety  and  tormenting  struggle  in  his  soul,  which  he  feels  he 
must  end  at  any  cost. 

Example  XXVII. — M.  R — ,  a  distinguished  chemist  and  amiable  poet,  of  a 
character  naturally  pliable  and  sociable,  came  to  place  himself  as  a  patient  in  one 
of  the  inlBrmaries  situated  in  the  Faubourg  Saint- Antoine.  Tormented  with  a 
homicidal  impulse,  he  would  often  prostrate  himself  before  the  altar,  and 
implore  the  Deity  to  deliver  him  from  this  atrocious  pro^jensity,  the  origin  of 
which  he  never  could  understand.  When  he  found  that  his  will  was  entirely 
under  the  control  of  this  impulse,  he  would  run  to  the  head  of  the  establishment 
and  cause  him  to  tie  his  two  thumbs  together  with  a  ribbon.  This  fragile  band 
sufficed  to  calm  the  unfortunate  R — ,  who,  however,  ended  by  attempting  to 
kill  one  of  his  keepers,  and  he  thereafter  died  in  a  violent  fit  of  rage.  R —  had 
left  behind  him  a  collection  of  letters,  in  which  he  attempted  to  describe  his  inter- 
nal sensations.  They  proved  that  this  desire  to  kill  some  one  was  wholly  unac- 
countable, and  arose  without  any  reason  whatever,  and  that  it  was  purely 
instinctive.  These  very  interesting  letters,  which  I  had  read  in  great  part,  fell 
into  the  hands  of  Dr.  Gall,  and  have  unfortunately  been  lost.  (Marc,  translated 
by  Ideler,  i.,  p.  169.) 

Example  XXVIII,— Catherine  Olhaver,  the  third  surviving  cliild  of  poor 
parents,  was  born  in  the  year  1788,  but,  in  consequence  of  her  mother  having  been 
seized  with  a  very  severe  fever,  she  was  weaned  when  only  six  weeks  old.  The 
first  symptoms  of  her  mothers  illness,  before  any  decided  signs  of  her  true  dis- 
ease manifested  themselves,  were  shown  in  the  desire  to  kill  her  child.  To 
accomplish  this  fearful  plan,  she  opened  one  side  of  her  feather  coverlet,  in  order 
to  put  the  child  therein,  with  the  double  purpose  of  suffocating  and  at  the  same 
concealing  it.  Her  intention  was  discovered  in  time  to  prevent  her  putting  it 
into  execution,  and  immediately  thereafter  she  was  seized  with  the  most  violent 
feverish  symptoms,  which  lasted  for  several  weeks.  After  her  recovery,  this 
woman  had  not  the  slightest  recollection  of  what  had  occurred,  and  devoted  her- 
self with  all  a  mother's  tenderness  to  the  care  of  her  child.  She  is  still  living,  and 
has  never  again  had  a  similar  attack. 

In  spite  of  the  poverty  of  her  parents,  Catherine  grew  up  perfectly  healthy, 
though  she  was  frequently  troubled  with  worms.  The  menses  appeared  late  in 
life,  but  further  than  this  there  was  no  irregularity.  She  became  with  child,  and 
on  the  21st  of  January,  1821,  she  was  happily  and  with  ease  delivered  of  a  healthy 
boy,  whom  she  herself  began  to  nurse.  Soon  after  her  delivery,  she  fell  into  a 
violent  rage,  and  was  attacked  thereafter  with  a  fit  of  epilepsy.  This  attack, 
however,  Avas  not  again  repeated.     When  her  child  was  six  weeks  old,  she  took 


186  STATES    OF   MENTAL   DEPRESSION. 

a  situation  as  wet-nurse  ;  and  she  conducted  herself  in  this  capacity  with  propri- 
ety, showing  lierself  of  a  quiet,  cheerful  disposition.  She  lavished  the  most 
tender  care  upon  her  charge,  whose  thriving  condition  gave  evidence  enough  of 
the  attentions  bestowed  on  it  by  the  nurse.  At  the  end  of  other  six  weeks,  she 
was  again  seized  with  a  violent  fit  of  anger  on  hearing  of  the  death  of  her  own 
child,  the  loss  of  which  she  attributed  to  the  carelessness  of  the  person  who  was 
rearing  it.  Acute  as  these  impressions  at  first  were,  they  became  speedily  effaced, 
and  she  only  lavished  her  maternal  cares  with  greater  assiduity  upon  her  nurs- 
ling. At  the  end  of  the  thirty -second  week  after  her  accouchement,  the  menses 
again  made  their  appearance,  preceded  by  a  slight  illness ;  and  about  the  fourth 
week  thereafter  the  same  thing  occurred.  From  this  time,  the  nursing  of  the 
chUd  was  evidently  too  much  for  her  strength.  She  became  pale  and  emaciated; 
the  child  also  began  to  ail,  being  first  seized  with  intermittent  fever,  and  then 
with  a  nervous  cough. 

On  Friday  and  Saturday,  the  20th  and  21st  of  October,  the  nurse  was  seized 
with  colic,  which,  more  or  less  severe,  lasted  until  the  Sunday,  though  consider- 
ably modified.  At  the  same  time  she  experienced  a  certain  agitation  in  her 
stomach,  and  anxiety  ;  but  this  did  not  last  for  any  time.  On  Sunday  evening, 
when  in  the  room  alone  with  the  two  youngest  children,  the  thought  suddenly 
flashed  across  her  mind,  on  seeing  a  knife  on  the  table,  that  she  must  kill  the 
nursling,  who  was  then  lying  in  her  lap,  by  cutting  her  throat  with  the  knife. 
She  stated  that  at  this  moment  she  felt  a  peculiar  movement  in  her  belly,  like  a 
gurgling,  as  she  expressed  it,  and  gusts  of  heat  towards  the  head  ;  and  she  heard, 
as  it  were,  a  voice  commanding  her  to  slay  the  child.  The  very  thought  of  this 
made  her  shudder ;  so  she  quickly  laid  the  child  upon  the  bed,  snatched  up  the 
knife,  and  flew  with  it  to  the  kitchen,  where  she  threw  it  from  her,  and  entreated 
the  cook  to  go  with  her,  and  not  to  leave  her,  because  she  was  beset  with  evil 
thoughts.  The  cook  answered  her  that  she  could  not  then  leave  her  work,  and 
thereafter  she  required  to  go  out ;  so  Catherine  again  returned  to  the  children. 
Still  the  thought  constantly  presented  itself  ;  and  in  order  to  drive  it  away,  she 
fell  to  singing  aloud,  dancing  with  the  children  i"Ound  and  round  the  room  until 
bedtime.  When  the  cook  had  again  returned  home,  the  nurse  begged  her  to 
remain  with  the  children,  and  she  would  occupy  her  place.  This  request  the 
cook  refused,  and  having  departed,  Catherine  went  to  bed,  slept  but  little,  and 
suddenly  awoke  with  the  ii'resistible  desire  to  murder  the  cliUd,  whose  crib  stood 
beside  her  bed.  Happily,  at  this  moment  the  door  opened,  and  her  mistress 
arrived.  This  somewhat  calmed  the  girl,  because  she  knew  that  the  mother  of 
the  child  and  her  sister-in-law  slept  in  the  same  room.  Still  she  slept  but  little, 
and  was  very  restless  the  whole  night,  when,  about  three  o'clock,  the  murderous 
impulse  was  so  strong,  that  she  sprang  out  of  bed  and  ran  to  wake  all  those  who 
were  present.  She  now  complained  that  she  felt  very  unwell,  and  was  beset 
with  unholy  thoughts,  without  stating  the  nature  of  them.  At  the  same  time, 
she  spoke  to  herself  as  if  she  were  delirious ;  suddenly  she  cried  out  aloud,  ' '  O  God, 
what  horrible,  what  frightful  thoughts!"  Soon  again,  "But  this  is  ridiculous, 
abominable,  terrific  !  "  Then  she  asked  with  anxiety  about  the  child,  whether  it 
was  really  beside  its  mother,  and  then  spoke  to  him  in  an  aflfectionate  and  tender 
manner  ;  and  after  she  had  taken  some  chamomile  tea,  she  became  more  quiet, 
and  slept  till  about  six  o'clock  next  morning.  The  day  following,  she  was  quite 
fatigued  and  overcome,  and  was  constantly  attacked  with  the  same  paroxysms. 
She  remained  perfectly  dumb  and  self-absorbed,  with  a  fixed  and  frequently 
ferocious  look,  and  face  of  unwonted  color,  and,  contrary  to  her  usual  habit,  took 
no  notice  of  the  child.  Finally,  about  five  o'clock  in  the  afternoon,  after  having 
three  times  taken  the  prescribed  draught,  she  experienced  more  calmness  and 
relief.  Only  once  after  this,  during  the  night  between  Monday  and  Tuesday,  did 
this  murderous  thought  again  obtrude  itself  ;  whereupon  she  leaped  from  her 
bed,  and  drank  of  the  potion  from  which  she  had  formerly  obtained  relief. 
Since  then  she  has  remained  free  from  all  simOar  attacks.  On  Thursday,  she, 
with  many  tears,  related  what  had  occurred  to  her. 

This  attack  did  not  come  on  synchronously  with  the  return  of  the  menses,  and 
not  the  slightest  cause  can  be  assigned  for  it.  The  medicines  employed  were 
potio  Riveri,  emetics,  and  valerian,  etc.  The  child  died  in  November,  and  the 
nurse  held  it  in  her  arms  during  the  last  moments  of  its  life,  ■wearing  at  the  same 
time  the  quiet  expression  of  the  profoundest  pain;  and  when  it  finally  died,  she 
fell  into  a  state  of  the  gi-eatest  despair,  which,  however,  soon  passed  away,  and 
gave  place  to  a  more  calm  sorrow.  (Mende,  in  Henke,  '  Zeitschrift  fiir  die 
iitaatsarzneikunde,'  1801.) 


STATES    OF    MENTAL    DEPRESSION.  187 

Example  XXIX. — The  wife  of  a  shoemaker  paid  me  a  visit  one  day  to  ask 
advice  about  a  complaint  concerning  which  she  was  in  despair.  She  presented 
all  the  appearance  of  sound  bodily  and  mental  health,  but  she  was  constantly 
beset  with  thoughts  tempting  her  to  kill  her  four  children,  whom,  as  she  said, 
she  loved  better  than  herself.  She  was  afraid  lest  she  should  do  some  evil  deed'; 
she  was  in  despair,  and  felt  inclined  to  throw  herself  over  the  window.  In  such 
moments  she  felt  an  almost  irresistible  impulse  to  some  such  perfectly  unaccount- 
able act,  and  in  consequence  of  which  she  was  seized  with  a  general  trembhn"-. 
Towards  other  children  she  felt  no  such  evil  disposition,  only  from  her  own  she 
must  flee  and  be  in  perpetual  fear  of  them,  and  carefully  hide  all  instruments 
which  might  possibly  fall  into  her  hands.  She  kept  constantly  running  up  and 
down  stairs,  in  order  that  by  the  very  motion  and  fatigue  she  might  drive  these 
notions  out  of  her  head.  This  homicidal  tendency  lasted  for  about  three  months, 
and  then  with  the  return  of  the  menses  suddenly  disappeared  of  itself.  (Georgeti 
'Discussion  Medico-legale  sur  la  Folie,'  1826.) 

Another  very  characteristic  case  may  be  found  mentioned  in  Gratiolet's 
*Anat.  comp.  du  Syst.  Nerv.,'  p.  578;  and  also  in  Guislain's  'Lemons  orales,' 
t.  i.,  p.  234  and  240;  Ellinger,  '  Zeitschrift  fur  Psychiatrie,'  1854,  xi.,  p.  466. 

As  to  these  sanguinary  impulses,  the  production  of  ideas  according 
to  the  law  of  contrast  (§  19)  is,  it  is  true,'  almost  the  only  point  of  con- 
nection between  them  and  the  normal  phenomena  of  mental  life;  altliough 
there  exists  a  very  great  difference  between  the  simple  fact,  that  in  the 
fortunate,  ideas  of  want  and  misery  may  easily  arise — in  the  lover,  ideas 
of  faithlessness — and  in  him  who  stands  on  the  brink  of  a  precipice, 
ideas  of  a  headlong  plunge  may  be  suggested,  and  the  actual  fulfilment 
of  those  ideas  which  lead  to  actions,  and  continually  and  persistently 
urge  towards  their  outward  expression. 

Somewhat  more  distinct  in  their  psychological  motives  are  those  cases 
which  come  under  the  second  category,  in  which  such  impulses  originate 
in  those  who  have  been  long  overwhelmed  with  grief,  concentrated  in 
self,  and  have  become  actual  misanthropes.  The  more  an  individual 
gives  himself  over  to  habitual  morbid  brooding  upon  his  own  condition, 
with  a  negative  disposition  of  the  feelings,  the  more  does  he  retire  upon 
himself,  and  withdraw  from  that  interchange  of  friendly  and  benevolent 
sentiments  which  knit  man  to  man;  and  gradually  he  arrives  at  that 
point  where  he  feels  himself  excluded  from  all  intercourse  with  his  fel- 
lows, and  all  that  interests  maiikind  at  large.  In  such  cases  we  often 
see  develoi:)ed  a  feeling  of  bitter  animosity  towards  the  world,  which  be- 
comes to  such  individuals  perfectly  hateful,  gloomy,  and  fearful;  and 
there  frequently  arise  impulses  to  commit  these  indeterminate  acts,  by 
which  the  individual  thinks  to  repay  the  world,  in  some  splendid  crime, 
for  all  these  griefs  and  imaginary  evils,  as  well  as  all  those  painful  im- 
pressions, the  cause  of  which  he  is  ever  seeking,  not  in  himself,  but  in 
the  outer  world.  At  times,  the  persons  who  are  most  frequently  with 
the  patient  draw  upon  themselves  his  most  intense  hatred,  and  become 
the  victims  of  these  impulses  which  the  patient  suddenly  discovers. 
More  frequently,  however,  it  is  neutral  persons  whom  he  attacks,  as  if 
the  feeling  of  hostility  which  animates  him  recognized  in  them  represen- 
tatives of  a  race  which  he  detests.  Frequently  it  is  the  innocent  play  of 
a  child  which  irritates  him,  or  the  beauty  of  a  woman  which  incites  in 
him  this  murderous  disposition. 

The  well-known  case  of  Henrietta  Cornier  appeared  for  a  long  time  to  belong 
to  this  category  (Marc,  ii.,  p.  48,  41).  But  Bonnet  ('  De  la  Monomanie  du  Meur- 
tre,'  Bordeaux,  1852)  tells  us  that  the  girl  Cornier  informed  her  prison  compan- 
ions that  it  was  to  avenge  herself  on  her  lover,  with  whom  she  had  been  living  in 


'  See  Ideler's  notes  to  the  fourth  and  ninth  sections  of  Marc's  work. 


188  STATES    OF    MENTAL    DEPBESSION. 

the  most  intimate  relations,  that  she  slew  her  child,  after  having  long  premedi- 
tated the  crime.  Examples  of  similar  tendencies  in  children  are  not  wanting 
(Marc,  i.,  p.  66;  Esquirol,  ii.,  p.  61;  and  in  the  work  of  Lallemand,  iii.,  p.  185, 
186).  In  many  of  these  cases  we  are  able  to  establisli  the  existence  of  different 
disturbances  of  the  general  health,  to  which,  from  experience,  we  are  bound  to 
attribute  a  certain  influence  in  the  production  of  cerebral  disease,  or  even  of  the 
actual  symptoms  of  this  affection,  e.  g.,  persistent  or  transitory  congestion  of  the 
head,  menstrual  derangements,  onanism,  diseases  of  the  genital  organs,  sensations 
of  anxiety  proceeding  from  the  cardiac  region,  weakness  of  vision,  general  feelitjg 
of  illness,  weakness,  constipation,  etc.  We  have  not  here  to  do  with  the  consid- 
eration of  these  facts,  in  a  medico-legal  point  of  view.  We  are  aware  that  such 
estimation  is  based  purely  upon  scientific  grounds,  resulting  from  the  most  mi- 
nute research  into  the  psychological  and  organic  causes  which  have  given  rise  to 
these  tendencies.  It  is  contemptible  to  see  how  often  science  is  constrained,  as  a 
last  remedy,  to  have  recourse  to  the  theory  of  those  morbid  impulses,  to  justify 
crimes,  and  seldom  (to  use  an  expression  of  Ideler's)  ought  medical  reports  to 
resemble  those  Italian  churches  where  every  bandit  finds  a  safe  asylum;  but  in 
such  cases  medicine  must  assert  her  rights,  and  never  ought  she,  when  opposed 
to  popular  opinion  and  prevailing  ideas,  which  rest  on  no  surer  ground  than  an 
imperfect  acquaintance  with  mental  disease,  to  throw  down  the  arms  which 
science  has  put  into  her  hands.  But  neither,  on  the  other  hand,  should  she, 
when  unable  to  give  a  determinate  opinion  on  scientific  grounds,  seek  to  establish 
one  on  any  other  basis. 

A  perfectly  distinct  group  of  cases,  which  in  a  medico-legal  point  of  view  it  is 
extremely  difficult  to  classify,  is  that  which  consists  of  those  who  kill  their  own 
children.  Many  of  those  individuals  are  drunkards,  or  persons  demoralized  by 
other  causes,  and  consequently  often  attacked  with  insanity.  Usually  they  de- 
clare that  they  kill  their  children  to  deliver  them  from  the  miseries  of  this  world; 
a  motive  which,  in  many  cases,  is  not  in  itself  so  wholly  unreasonable.  Often, 
after  having  committed  a  murder,  these  persons  make  an  attempt  to  commit 
suicide — or  rather  they  intend  to  do  so,  but  are  too  faint-hearted  to  carry  it  out. 
In  a  good  number  of  cases  the  act  partakes  really  of  the  character  of  self -mutila- 
tion, and  as  it  were  of  suicide,  through  the  murder  of  another;  as  when  the  im- 
fortunate  father  who  tenderly  loves  his  child  seeks,  in  killing  him,  to  slay  him- 
self. 

The  pyschological  problems  in  these  cases  (we  shall  return  to  them  again  m 
another  place)  are  usually  but  little  cleared  up  by  any  declarations  which  the  in- 
dividuals themselves  may  make,  who  in  general  belong  to  the  uneducated  class, 
and  can  give  no  account  whatever  of  their  state  of  mind.  In  legal  medicine, 
we  ought  to  adhere  most  strictly  to  the  course  of  events,  to  the  remarkable 
changes  which  may  have  taken  place  anteriorly  in  the  moral  individuality  of 
the  person;  to  inquire  if  he  has  ever  been  subject  to  hallucinations,  and  into  his 
condition  both  before  and  after  the  act.  In  the  case  to  which  we  have  referred 
above  (Seitz,  §  41)  tliis  most  incredible  fact  came  out,  viz.,  that  the  individual, 
after  having  slain  his  three  children,  washed  his  hands,  threw  himself  upon  the 
grass,  and  went  to  sleep  for  two  hours.  He  was  perfectly  incapable  of  experi- 
encing the  least  remorse  for  his  conduct.  Hence  we  must  come  to  the  conclusion 
that  in  such  cases  the  acts  of  the  individual  are,  at  least,  of  as  much  importance 
as  his  words  in  helping  us  to  arrive  at  a  just  appreciation  of  his  mental  condition. 
Another  class  of  cases  consists  of  those  where  the  individual  commits  crimes 
in  order  to  die  upon  the  scaffold.  They  prefer  that  mode  of  death  to  suicide, 
because  they  have  not  the  courage  to  kill  themselves,  or  because  they  consider 
that  suicide  is  too  gross  a  sin,  and  that  they  could  not  confess  before  death,  etc. 
There  is  scarcely  one  of  those  individuals  in  this  class  whom  we  could  consider 
as  in  the  full  enjoyment  of  reason.  M.  Brierre  de  Boismont  has  brought  together 
six  cases  of  this  description  ('Ann.  Med.  Psych.,'  1851,  iii.,  p.  626). 

§  129.  Closely  related  to  those  impulses  which  have  just  been  exam- 
ined, stand  those  morbid  inclinations  which  we  see  also  discovered  by 
melancholies,  which  impel  them  to  the  destruction  of  inanimate  objects, 
and  which  may  be  directed  against  anything  oi"%verything  that  surrounds 
the  patient.  Thus,  there  are  some  who  have  a  constant  desire  to  tear 
their  clothes  and  beds,  to  make  cliariyie  of  them,  etc.  Most  interesting, 
however,  are  those  cases  in  which  the  deed  consists  of  fire-raising,  which 


STATES    OF    MENTAL    DEPRESSION.  189 

has  been  erected  into  a  special  monomania,  and  described  under  the 
name  of  Pyromania — a  classification  purely  artificial,  but  which  possesses 
at  least  the  advantage  of  previously  settling  the  object  of  discussion.' 

If  from  the  observations  whicli  have  been  published  upon  this  subject 
we  exclude  all  those  cases  where  egotistical  motives''  have  evidently 
guided  the  hand  of  the  incendiary,  there  still  remains  a  certain  number 
in  which  this  crime  of  arson  has  been  committed  by  patients  laboring 
under  a  well-marked  melancholia  (particularly  of  nostalgia  passing  into 
mania) — a  state  which  is  often  accompanied  by  important  derangements 
in  the  general  health,  and  frequently  in  the  sexual  organs.  The  morbid 
impulse  develops  itself  precisely  in  the  same  manner  as  does  the  homi- 
cidal impulse  which  we  have  just  been  studying.  The  feeling  of  mental 
anxiety  and  the  general  disturbance  which  arises  from  the  morbid  condi- 
tion of  the  faculties  do  not,  as  has  been  said  (Masius),  impel  the 
individual  to  seek  to  stifle  this  anxiety  by  the  sight  of  a  great  flame,  but 
merely  to  relieve  by  an  outward  act,  however  negative  and  destructive  m 
character,  the  profound  discord  and  uneasiness  which  rules  within,  and 
thereby  to  obtain  peace  and  tranquillity.  The  particular  direction  which 
this  morbid  impulse  takes,  viz.,  incendiarism,  may  arise  from  the  fact 
that  to  those  persons  in  whom  this  tendency  has  been  most  accurately 
observed — namely,  young  people,  particularly  young  maid-servants — fire, 
with  which  they  in  the  performance  of  their  duties  have  much  to 
do,  is  always  ready  at  hand,  and  presents  itself  as  the  readiest  means  by 
which  they  can  satisfy  the  morbid  craving  which  torments  them — a 
means  which  is  easily  employed ;  and  which  requires  neither  great  energy 
of  action  nor  violent  determination  to  make  use  of. 

Away,  then,  with  the  term  Pyromania,  and  let  there  be  a  careful  investigation 
in  every  case  into  the  individual  psychological  peculiarities  which  lie  at  the 
bottom  and  give  rise  to  this  impulse.  The  grand  question  in  foro,  in  aU  such 
cases,  must  ever  be  to  ascertain  whether  there  existed  a  state  of  disease  which 
limited,  or  could  have  limited,  the  liberty  of  the  individual.  Sometimes  the 
symptoms  of  undoubted  mental  disease  can  be  clearly  distinguished — a  dominant 
feeling  of  anxiety,  hallucinations,  states  of  hysterical  exaltation;  in  other  cases, 
the  actual  existence  of  a  nervous  disease  (epilepsy  or  chorea)  renders  probable 
the  assumption  that  the  accused  has  been  subject  to  some  passing  mental  aber- 
ration. We  should  not  forget  that  usually  very  little  is  wanted  to  interfere  with 
the  liberty  of  action  in  such  persons  (>5  36);  they  are,  for  the  most  part,  young, 
childish,  or  half-childish,  often  morally  and  intellectually  weak,  silly,  and  ca- 
pricious individuals.  The  incendiary  act  often  appears  to  be  utterly  without  any 
motive, — the  feeble  ego  having  opposed  no  resistance  to  the  thought  of  the  deed 
w^hich  suddenly  sprang  up. 

Of  course,  there  are  also  cases  where  the  insane  set  fire  to  buildings  under  the 
impulse  of  motives  very  different.  Jonathan  Martin,  who  burned  the  Cathedral  of 
York,  was  not  a  melancholic,  but  was  evidently  laboring  under  chronic  partial 
dementia,  and  it  was  in  consequence  of  his  hallucinations  that  he  sought  "to 
purge  the  house  of  the  Lord  of  the  unworthy  priests  "  who  dwelt  in  it.  To  in- 
clude this  case  under  the  title  of  '-Pyromania"  (e.  g.,  Pinel,  'Path.  Cerebr.,'  p. 
328)  is  the  necessary  but  evil  result  of  a  superficial  classification. 

Example  XXX. — Melancholia  with  a  quiet  destructive  inqndse. — Marie  Z — , 
aged  about  30  years,  of  an  eccentric  character,  became  mentally  affected  after  the 
occurrence  of  some  family  annoyances.  She  believed  herself  lost,  and  condemned 
to  the  punishments  of  hell.  After  having  attempted  to  commit  suicide,  slie  came 
into  our  asylum  with  a  blue  mark  in  the  neck,  and  bearing  the  traces  of  the  cord 

'  See  the  copious  Gerraan  literature  on  this  subject  by  Osiander,  Henke, 
Meckel,  Masius,  Flemming,  Mayer,  Hettich,  etc.,  and  recently  Willers-Jesseu. 

^  Sometimes  revenge,  sometimes  boyish  delight  in  mischief — sometianes,  and 
indeed  most  frequently,  the  opinion  that  by  destroying  the  house  they  might 
put  an  end  to  an  impatiently  borne  period  of  service  and  return  home. 


190  STATES    OF    MENTAL    DEPRESSION. 

with  which  she  had  sought  to  strangle  herself.  After  her  admission,  she  aban- 
doned herself  to  the  utmost  despair;  from  morning  till  night  she  remained  seated 
upon  her  bed,  her  head  concealed  in  her  hands,  and  replied  to  questions  only  in 
monosyllables.  Sometimes  she  discoursed  at  length  upon  the  frightful  punish- 
ment which  was  awaiting  her.  One  day  she  begged  for  a  pair  of  scissors,  and 
deliberately  proceeded  to  riddle  a  mattress  and  her  hood  with  a  mass  of  llitte 
holes,  and  this  without  the  slightest  trace  of  bitterness  or  anger;  and  she  told  me 
very  naively  that  she  was  urged  to  do  so  by  an  irresistible  impulse.  She  com- 
pletely recovered  at  the  end  of  two  years.     (Guislain,  '  Phrenopathies.') 

Section  V. — Melancholia  ivith  Persistent  Excitement  of  the  Will. 

In  the  last  two  sections  we  have  studied  those  conditions  in  which  the 
morbid  state  of  the  faculties  manifests  itself  by  a  tendency  to  destruction. 
Now,  the  more  the  motive  power  of  the  soul  is  excited  by  mental  pain, 
and  the  more  general  extended  and  persistent  the  manner  in  Avhich  this 
is  done,  and  the  more  vague  and  permanent  the  excitement,  the  less  are 
we  inclined  to  regard  this  condition  as  one  of  melancholia,  and  the  nearer 
does  it  approach  to  the  form  of  mania.  It  is  useless  and  impossible  to 
describe  here  all  those  intermediate  forms  through  which  this  transition 
from  melancholia  passes  into  maniacal  excitement;  we  shall  exhibit  in 
the  following  section  the  most  pronounced  form  of  this  state. 

But  it  is  of  importance  to  know  that  there  are  certain  conditions  in 
which  the  negative  disposition  of  the  faculties  and  permanent  excitement 
of  the  will  are  kept  within  moderate  bounds,  and  present  a  very  chronic 
course;  conditions  which  exhibit  themselves  rather  m  an  habitual  eccen- 
tricity of  character,  and  which  are  nearly  allied  to  those  of  slight  and 
chronic  melancholia,  to  which  we  have  already  referred,  and  of  which 
they  represent  the  active  form.  Some  of  these  cases  are  described  by 
authors  as  cases  of  mental  insanity,  tnatiia  sine  delirio,  folic  raisonnantCy 
moral  insanity  (Prichard).  These  conditions  are  congenital  or  acquired; 
they  are  characterized  by  a  feeling  of  discontent  and  bitterness,  which  is 
either  constant  or  roused  on  the  slightest  provocation;  by  a  perpetual 
negative  demeanor  towards  the  external  world,  the  impressions  of  which 
always  are,  or  very  easily  become,  painful  in  their  nature;  and  by  a  con- 
stant reaction  of  the  will,  in  the  sense  of  the  contrary  choleric  disposi- 
tion. Generally  this  condition  is  not  recognized  as  a  morbid  one,  or  it  is 
only  after  a  long  time  that  we  come  to  look  upon  these  individuals  as 
actually  invalids.  They  well  know  how  to  justify  by  logical  arguments 
their  wayward  and  unreasonable  behavior,  and  how  to  dissimulate  until 
there  arrives  a  moment  when  this  state  suddenly  passes  into  an  access  of 
mania,  which  serves  to  tear  the  veil  from  the  eyes  of  their  friends  and 
reveal  them  in  their  true  character. 

Example  XXXl.— Habitual  perversion  of  the  feelings,  with  impulsive  fits  of 
anger,  without  any  derangement  of  the  intellect. — An  only  son,  brought  up  under 
the  eyes  of  a  weak  and  indulgent  mother,  early  acquired  the  habit  of  yielding  to 
all  his  caprices,  and  to  all  the  impulses  of  a  restless  and  ardent  temperament. 
With  years  the  impetuosity  of  his  desires  only  augmented,  and  the  fortune  which 
was  lavishly  supplied  at  his  request  seemed  to  level  every  obstacle  which  stood  in 
the  way  of  his  supreme  will.  If  he  met  with  any  serious  difficulty,  he  became 
exasperated  and  much  enraged;  he  attacked  with  boldness,  and  sought  to  rule 
everything  by  force,  and  was  perpetually  quarrelling  and  fighting.  If  he  was 
angry  with  any  beast— a  dog,  a  sheep,  or  a  horse,  it  mattered  not  which— he  im- 
mediately made  an  end  of  it.  When  in  company?  or  a  guest  at  any  fete,  he 
usually  got  into  a  rage  and  then  fell  to  fighting.  On  the  other  hand,  full  of  rea- 
son when  he  was  quiet,  and  master  of  a  large  estate,  he  conducted  his  affairs  with 
the  greatest  good  sense  and  uprightness,  fulfilled  his  duties  to  society,  and  made 
himself  known  by  his  liberality  to  the  poor.    Hitherto  his  unfortunate  propensity 


STATES    OF    MENTAL    DEPRESSION.  191 

for  getting  into  quarrels  had  only  brought  him  bruises,  actions  at  law,  and  pecu- 
niary  fines;  but  one  notorious  case  put  an  end  to  his  acts  of  violence,  for  one  day 
he  got  into  a  rage  at  a  woman  who  was  abiising  him,  and  threw  her  into  a  spring. 
The  affair  came  before  the  court,  and  on  the  testimony  of  a  crowd  of  witnesses, 
who  deposed  to  the  intemperateness  of  his  fits  of  anger,  he  was  sentenced  to  be 
confined  in  the  asylum  of  Bicetre.     (Pinel,  '  Traite  de  I'Alienation,'  p.  159.) 


192  STATES    OF    MENTAL    EXALTATION. 


CHAPTER  11. 
STATES  OF  MENTAL  EXALTATION. 

Mania. 

§  130.  While  the  pure  and  simple  forms  of  melancholia  represent 
conditions  of  depression  of  the  self-sensation  and  self-confidence,  of  con- 
centration upon  some  painful  emotion,  of  morbid  self-concentration,  and, 
in  the  highest  degrees,  of  even  incapacity  for  making  the  slightest  exertion, 
we  have  seen  that,  in  the  forms  last  considered,  the  emotional  disposition 
is  always  more  and  more  accompanied  by  morbid  impulses  to  manifesta- 
tions of  volition.  The  possibility  of  exhibiting  the  emotion  by  actions, 
and  of  thereby  obtaining  relief,  shows  that  the  affective  sphere  of  the 
mind  and  the  will  have  become  more  free;  indeed,  the  stronger  and  more 
persistent  these  impulses  are,  and  the  more  extended  and  independent 
this  aspiration  to  freedom  becomes,  the  more  there  result  states  ot persis- 
tent excitement  and  exaltation  of  luill,  with  which  also  there  is  easily 
united  an  increase  of  the  self-sensatio?i  and  of  self-confidence.  Such  con- 
ditions, which  have  been  appropriately  designated  (Jessen),  in  opposition 
to  melancholia,  morbid  states  in  which  the  patients  are  07it  of  themselves, 
are  comprised  under  the  name  of  mania;  and  under  this  head  there  are 
included  two  different  forms,  which,  while  they  are  intimately  connected 
with  each  other,  and  not  unfrequently  pass  into  each  other,  occur  still 
more  frequently  as  states  or  forms  fragmentarily  mixed  together,  viz. 
matiia  and  monomania  (sensu  strictiori). 

The  fundamental  affection  in  the  maniacal  states  consists  chiefly  in  a 
derangement  of  the  motory  side  of  the  soul-life,  the  effort,  and  of  such  a 
nature,  that  the  latter  having  become  free,  unrestrained,  and  considerably 
increased,  the  individual  consequently  feels  impelled  to  give  some  out- 
ward manifestation  of  his  powers.  From  this  tendency  to  an  exaggerated 
psychical  movement  from  within  outwards,  from  this  augmented  energy 
and  more  extended  range  of  the  efforts,  from  this  extravagance  of  the 
will,  which  constitute  the  centre-point  of  maniacal  derangement,  spring, 
as  from  a  common  source,  those  two  forms  which  in  their  nature  and 
mode  of  manifestation  are  sometimes  so  essentially  distinct.  On  the  one 
hand,  this  necessity  for  the  manifestation  of  the  increased  mental  activity 
may  manifest  itself  directly,  being  propagated  by  a  continuous  impulse 
to  the  organs  of  motion,  and  there  exploding,  as  it  were;  whence  there 
ensues  a  state  of  great  physical  restlessness,  the  patient  keeping  his  mus- 
cles in  constant  play  (speech,  gestures,  movements  of  the  body  generally), 
and  perpetually  speaking,  shouting,  weeping,  dancing,  leaping,  storming, 
etc. ;  and  thus  is  constituted  the  form  generally  called  mania. 

Or,  on  the  other  hand,  the  direct  result  of  this  more  free  development 
of  volition  may  be  the  development  of  inordinate  vanity,  increased  self- 
sensation,  and  consequently  a  constant  over-estimation  of  self;  and  as  at- 
tempts at  explanation  of  this  disposition,  delirious  conceptions  arise  which 
now  become  dominant  over  the  mind,  and  take  the  increased  activity  of 


STATES    OF    MENTAL   EXALTATION.  193 

the  will  into  their  service.  The  patient  has  now  no  longer  to  do  with  mere 
general  manifestation  of  energy;  but  this  excitation  of  the  motory  side  of 
the  soul-life  is  transformed  into  extravagant  volition  in  the  form  of  parti- 
cular delirious  conceptions,  for  the  most  part  with  much  greater  outward 
calm.  As  soon  as  such  a  condition,  accompanied  by  delirious  conceptions 
arising  from  inordinate  self-conceit,  has  in  any  degree  become  fixed,  there 
is  founded  a  state  of  mental  derangement  infinitely  more  serious  than  that 
of  simple  mania.  In  short,  while  in  the  latter  form  the  patient  is  freed 
from  his  exaggerated  impulses  by  their  outward  manifestation,  and  again, 
as  we  shall  soon  show  in  the  pure  form  of  mania,  the  whole  disease  is 
•confined  to  a  relatively  external  sphere  of  the  mental  life  without  pro- 
foundly involving  the  individuality,  it  is  the  essential  characteristic  of 
this  second  form  of  mania,  which  we  designate  monomania,  that  delirious 
conceptions,  false  ideas,  which  arise  from  over-estimation  of  self,  and 
therefore  relate  only  to  the  special  self  of  the  patient,  appear,  which  im- 
mediately involve  the  ego  itself,  and  therefore  the  innermost  part  of  the 
individuality  becomes  alienated  and  falsified. 

§  131.  But  if  these  two  forms  in  their  extreme  degrees  are  so  utterly 
distinct  as  mutually  to  exclude  the  possibility  of  mistaking  the  one  for 
the  other,  still  observation  shows  that  in  mania  itself  such  delirious  ideas 
of  self-importance  are  by  no  means  unfrequent,  which  certainly  ought 
not  to  be  regarded  in  an  ontological  sense  as  '' fragments  of  monomania," 
as  phenomena  of  quite  another  affection  which  in  this  case  present  them- 
selves in  a  very  simple  form,  but  as  the  result  of  the  primary  mental  con- 
dition. Thus  it  is  self-evident  that,  in  the  direct  evolution  of  the  morbid 
impulse  of  will  in  muscular  movements,  this  arrogant  disposition  must 
very  frequently  give  rise  to  this  condition  of  overweening  self-estimation, 
and  consequently  how  readily  the  patient  may  come  to  acquire  delirious 
conceptions;  and  one  can  see  any  day  in  watching  maniacs  how  sometimes 
such  grand  ideas  are  barely  visible,  while  in  others  they  are  developed 
with  the  greatest  clearness.  Fortunately,  however,  there  exists  in  these 
most  advanced  cases  of  mania  a  something  which  prevents  these  ideas 
from  becoming  fixed.  They  share  in  the  tumult  and  precipitancy  which 
agitate  the  motory  sphere  of  the  soul-life;  they  become  so  confused  in 
their  hurry,  and  pursue  each  other  so  rapidly,  that  they  have  no  time  to 
become  fixed  or  to  dwell  in  the  mind.  On  the  other  hand,  where  this 
rajiid  succession  of  ideas  does  not  exist,  and  where  this  state  of  exaltation 
and  these  delirious  conceptions  penetrate  the  ego  so  deejjly  and  in  such  a 
manner  as  actually  to  form  an  essential  and  constituent  part  of  it,  and  to 
become  not  only  a  subjective  reality  to  the  patient,  but  the  ruling  princi- 
ple of  his  whole  psychical  life,  this  state  is  called  monomania. 

The  distinction  between  mania  and  monomania,  as  we  have  observed 
it  in  the  most  marked  and  characteristic  cases,  consists  chiefly  in  the 
different  direction  which  the  original  lesion  takes,  in  the  different  manner 
in  which  the  intellect  is  morbidly  changed,  and  the  way  in  which  the  ego 
is  affected.  In  mania,  the  exaggerated  impulse  of  the  will  immediately 
passes  outwards  as  a  tendency  to  muscular  movement;  in  monomania  it  is 
simply  an  internal  eccentricity  of  will,  whereby  the  internal  feeling  of 
greater  liberty  of  action  is  transformed  by  a  reactionary  process  into 
exalted  false  ideas,  and  where  this  feeling,  when  it  manifests  itself,  is  no 
longer  confined  to  simjile  movements  and  relief  through  these  move- 
ments, but  tends  rather  towards  the  realization  of  certain  plans  which 
proceed  from  those  false  ideas.  This  error  in  the  ideas  consists  in  fixed 
delirious  conceptions  in  regard  to  the  special  individual itv  springing  from 
13 


194  STATES    OF    MENTAL    EXALTATION. 

this  OYer-estimatioii  of  self;  while  in  mania,  the  derangement  of  the  in- 
tellect consists  chiefly  in  a  delirious  confusion  of  ideas  in  consequence  of 
the  precipitous  haste  with  which  all  the  mental  processes  are  conducted. 
Finally,  we  shall  have  to  consider  a  third  state  of  mental  exaltation, 
more  apparent  than  real,  which  is  never  found  except  in  monomania,  and 
Avhich  consists  in  this — that  the  anomaly  of  the  psychical  self -sensation, 
tliis  overweening  disposition  whicii  has  originally  given  origin  to  all  those 
false  conceptions  by  which  the  patient  seeks  to  explain  his  state,  disap- 
pears more  or  less  completely;  but  the  false  conceptions  themselves,  the 
exalted  ideas  which  the  individual  entertains  of  his  own  merits,  let  loose 
from  the  foundation  on  which  they  were  erected,  persist,  and  as  constantly 
present  errors  of  judgment,  completely  govern  the  whole  intellectual 
life  of  the  patient.  We  shall  describe  this  third  condition  under  the  title 
of  Partial  Dementia  with  Exaltati07i,  in  the  third  section  of  this  book. 

In  mania,  as  in  melancholia,  there  exists  an  important  difference  between  the 
cases,  in  regard  to  whether  the  patients  are  in  a  simply  superficial  or  in  a  pro- 
found dreamy  state,  whether  their  relations  with  the  outer  world  are  clear,  or  are 
hazy,  confused,  and  obscure.  Upon  this  depends  in  great  part  the  degree  of  re- 
collection of  their  state  which  the  patients  possess  after  their  recovery. 

§  132.  We  have  more  than  once  had  occasion  to  remark  that,  in  the 
majority  of  cases,  melancholic  states  precede  the  maniacal,  and  that  the 
latter  is  engendered  by  the  former.  In  the  more  chronic  cases  we  often 
have  the  opportunity  of  following  the  whole  course  of  the  disease,  and  of 
seeing  in  melancholies  the  mental  suffering  and  anxiety  increase  from  day 
to  day,  at  first  manifesting  itself  merely  by  extreme  restlessness,  but  grad- 
ually passing  into  complete  mania.  In  such  cases  it  is  undoubtedly  the 
state  of  mental  suffering  which  induces  this  convulsive  condition — a  phe- 
nomenon which  may  appropriately  enough  be  compared  on  the  one  hand 
to  those  convulsions  which  are  brought  on  by  some  particularly  severe  bod- 
ily suffering,  and  at  other  times  to  those  involuntary  muscular  contrac- 
tions which  take  place  as  a  sort  of  instinctive  reaction  against  any  acute 
pain  (as  setting  the  teeth,  clenching  the  fist,  etc.). 

We  are  not  to  suppose  that,  therefore,  the  nature  of  mania  consists 
merely  in  the  unregulated  and  uncurbed  manifestation  of  the  negative 
disposition  found  in  melancholiii.  For,  though  often  enough  this  disposi- 
tion breaks  through  all  barriers,  and  displays  itself  in  certain  acts  of  con- 
vulsive fury  or  of  destruction — conditions  which  we  have  already  described 
under  the  title  of  raptus  melancholicus;  and  although,  often  enough, 
during  the  Avhole  course  of  the  maniacal  affection,  the  melancholia  appears 
behind  it  as- a  shady  background,  and  there  are  even  times  when  it  ad- 
vances to  the  foreground  and  may  again  become  dominant;  still  the  mania,, 
when  once  the  mo'tory  exaltation  has  been  set  free,  however  short  the  fit 
may  be,  becomes  entirely  independent  of  the  preceding  melancholia,  and 
bursts  forth  without  the  necessity  of  being  excited  anew  by  melancholic 
emotions:  indeed,  the  disposition  frequently  undergoes  a  total  change, 
the  patient  becoming  joyful,  merry,  and  overforward. 

At  the  same  time,  those  deeds  of  destruction,  the  savage  attempts  and 
ferocious  acts  committed  by  maniacs,  are  far  from  being  always  due  to  a 
"^true  negative  disposition  of  mind,  or  to  even  a  momentary  hostile  inten- 
tion; much  more  frequently  the  acts  of  these  patients  are  the  result  of  a. 
blind  impulse  to  action,  of  a  necessity  to  change  the  external  world 
according  to  their  will.  In  acts  of  destruction  this  desire  finds  its  sim- 
plest fulfilment,  because  this  is  so  much  easier  than  to  create  anything — 
for  this  demands  a  certain  amount  of  reflection  and  of  care,  of  Avhich 


STATES    OF    MENTAL    EXALTATION.  195 

maniacs  are  wholly  incapable.  The  desire  longs  to  be  promptly  satisfied, 
and  convnlsively  hastens,  so  to  speak,  to  manifest  itself  without  heeding 
the  more  slow  influence  of  more  orderly  thoughts:  as  he  must  give  vent 
to  his  desire  in  a  visible  manner,  he  proceeds  at  once  to  the  work  of  de- 
molition; and  that  which  we  might  be  inclined  to  regard  as  the  object  of 
the  deed,  is,  in  fact,  merely  the  termination  of  his  activity.  We  see 
something  analogous  to  this  in  the  child  who  destroys  his  toy  in  the 
endeavor  to  satisfy  that  necessity  that  he  discovers  of  making  it  to  suit 
his  idea,  or  in  schoolboys  who  wrestle  with  each  other  in  order  to  satisfy 
the  longing  they  experience  to  exhibit  their  strength.  In  the  same  way, 
maniacs  often  demolish  and  destroy  things  amidst  shouts  of  laughter  and 
in  the  greatest  good-humor.  But  there  exists  a  complete  and  marked 
difference  between  the  actions  in  mania  and  the  deeds  of  the  melancholic 
in  the  form  of  monomania,  an  affection  Avhich  in  its  internal  causes  is  so 
closely  connected  to  mania.  The  monomaniac  more  frequently  desires 
actually  to  create  something,  and,  indeed,  to  execute  some  prodigious  work, 
and  to  bring  it  to  the  light  of  day;  and  he  may  even  bring  to  bear  upon 
this  some  amount  of  reflection,  because,  in  his  case,  the  mental  processes 
do  not  proceed  with  the  haste,  restlessness,  and  confusion  present  in 
mania;  but  there  is  time  afforded  for  the  impulse  which  the  patient  feels 
to  expend  liis  force,  to  be  governed  by  some  fixed  great  and  regulated, 
but  naturally  false  idea,  according  to  which  he  is  impelled  to  work. 

When  mania,  particularly  that  form  accompanied  with  furious  delirium,  has 
proceeded  out  of  melancholia  in  the  manner  we  have  already  indicated,  we  never 
dream  of  attributing  to  the  person  so  affected  any  premeditated  mental  act;  in 
fact,  it  is  out  of  the  question  to  think  of  looking  for  any  psychological  progress 
regulated  by  the  faculties  in  an  individual  laboring  under  such  an  affection. 
That  mental  act  which  he  apparently  performs  is  rather  a  modification  or  change 
in  his  morbid  disposition,  which  goes  on  without  any  intervention  on  his  part, 
and  is  explicable  on  the  ground  that  some  change  has  taken  place  in  the  nature 
and  form  of  his  cerebral  affection.  So  long  as  this  process  is  confined  to  a  simple 
change  of  disposition,  the  lesion  is  limited  to  a  sphere  relatively  exterior  or  peri- 
pheral to  the  mental  faculties,  and  frequently  the  patient  has  then  a  consciousness 
of  his  condition,  of  that  mental  anomaly  which  weighs  upon  him,  which 
oppresses  the  ego,  which  seems  to  exact  something  of  him,  and  which  he  cannot 
resist;  and  with  this  consciousness  he,  at  the  same  time,  protests  against  the  im- 
minence of  the  disease. 

When  mania  does  break  out,  it  is  by  no  means  always  determined  by  a  pas- 
sionate or  emotional  (melancholic)  shock.  Apart  from  those  cases  of  mania  caused 
by  acute  meningitis,  we  see  in  other  forms  of  deUrium — as,  for  example,  of 
typhus  fever — the  same  outward  restlessness,  the  voluntary  acts  and  impulsive 
movements,  the  result  at  one  time  of  the  profound  anxiety  which  torments  the 
patient,  or  at  another  provoked  by  hallucinations,  while  again  they  may  come 
on  without  any  appreciable  cause,  as  if  this  motory  impulse  commenced  spontan- 
eously to  show  itself  with  the  more  profound  destruction  of  the  mental  faculties. 

A  similar  state  of  matters  prevails  in  certain  cases  of  chronic  mania.  For 
observation  has  distinctly  shown  than  when  the  brain  has  once  been  the  seat  of  a 
lesion  partaking  of  the  nature  of  mental  pain,  there  remains  a  condition  in  the 
highest  degree  predisposing  to  mania.  Mania  succeeds  melancholia — such  is  the 
rule;  there  are  cases  even  where  long  after  recovery  from  melancholia  a  second 
attack  of  insanity  has  come  on,  but  this  time  assuming  the  form  of  mania.' 

Section  I. — Mania. 

§  133.  As  we  have  already  remarked,  it  is  rare  that  mania  shows  itself 
■without  having  been  preceded  by  certain  symptoms  of  some  other  mental 
affection.     In  the  majority  of  cases,  for  some  time  previous,  the  desires, 

'As,  for  example,  the  ninth  case  of  Jacobi  ('Hauptformen,'  etc.).  Zeller  and 
myself  have  observed  similar  cases. 


196  STATES    OF    MENTAL    EXALTATION. 

the  feelings,  and  habits  of  the  patient  have  become  entirely  changed 
and  generally  a  tone  of  melancholy  seems  to  pervade  them.  This  ante- 
cedent stadium  melancholium,  which  may  be  of  a  very  gentle  and  tran- 
sient nature,  is  what  has  been  termed  the  period  of  incubation  of  mania. 
The  melancholic  gradually  becomes  very  restless,  nothing  pleases  him; 
he  is  perjDetually  wandering  about ;  he  strays  amongst  the  fields,  or 
makes  excursions  to  see  friends  and  relatives,  frequently  to  far-distant 
places,  with  the  vague  expectation  of  obtaining  relief.  He  gives  evidence 
of  his  distressing  delirium,  when  such  exists,  by  talking  in  a  loud  voice, 
and  by  his  loquaciousness;  his  voice  is  stronger  on  such  occasions  than 
usual,  and  he  is  generally  more  active.  In  particular,  his  appetite  is 
actually  voracious;  he  frequently  comjjlains  of  disagreeable  sensations  in 
the  epigastric  region,  of  a  feeling  of  oppression  which  extremely  annoys 
and  torments  him.  Persons  who  have  once  had  an  attack  of  mania  fre- 
quently themselves  say  that  they  are  going  to  have  a  relapse,  and  beg  that 
they  may  be  watched  and  removed  from  their  usual  neighborhood.  Fre- 
quently such  persons  exhibit  a  great  desire  for  spirituous  liquors;  and  as 
they  yield  to  the  desire  usually  in  an  immoderate  degree,  it  seems  as  if 
they  would  by  the  alcoholic  stimulus  perpetuate  and  increase  their  state 
of  excitement,  wliich  unfortunately  they  too  often  succeed  in  doing. 
With  the  increased  muscular  activity  and  impulse  to  exhibit  it  in  actions^ 
new  ideas  and  new  sensations  arise,  which  at  first  plunge  the  patient  into 
a  state  of  astonishment  and  fear,  but  speedily  end  by  gaining  the  com- 
I^lete  mastery.  At  the  commencement  he  could  conceal  this  state  of 
mind,  but  soon  these  new  ideas  and  sensations  slip  out  and  display  them- 
selves in  words  and  deeds. 

Simultaneously  with  these  psychical  symptoms,  there  are  usually  pres- 
ent in  this  first  stage  certain  signs  of  derangement  of  the  digestive  func- 
tions, of  the  circulation,  and  of  nutrition.  At  first,  there  is  a  feeling  of 
illness,  great  prostration;  pain  in  the  head,  teeth,  and  abdomen;  sleep- 
lessness, agitating  dreams,  hallucinations  of  the  senses,  vertigo;  redness, 
or,  on  the  contrary,  paleness  of  the  countenance,  emaciation,  and  a  yel- 
lowish tint  of  the  skin;  enormous  appetite,  foul  tongue,  and  constipa- 
tion; palpitation,  frequent  pulse,  and  a  generally  febrile  state;  suppres- 
sion of  the  menses,  and,  not  unfrequently,  exaggeration  of  the  sexual 
desires.  The  form  of  the  visage  becomes  changed;  there  is  often  slight 
general  trembling  of  the  whole  body;  the  sensation  of  heat  and  cold,  and 
of  bodily  pain,  is  weakened.  When  the  mania  is  fully  pronounced,  the 
feeling  of  illness  disappears,  and  the  patient  expresses  himself  as  quite 
well. 

We  shall  now  proceed  to  examine  more  minutely  this  form  of  insanity 
in  its  fully  developed  state;  but  before  proceeding  we  must  remark  in 
passing,  that  in  consequence  of  the  multiplicity  and  infinite  variety  of 
symptoms  of  this  form  of  mental  disease,  it  will  be  necessary  to  divide 
them  into  groups  of  phenomena,  which,  of  course,  will  not  all  be  found  in 
each  individual  case. 

134.  1.  Anomalies  of  the  disposition,  of  the  desires,  and  of  the  will. — 
The  fundamental  disorder  in  mania,  the  irritation  upon  the  motory  side 
of  the  soul-life,  exhibits  itself,  first  of  all,  in  this  sphere,  as  a  high  degree 
of  mental  excitement,  with  restless,  impetuous,  and  violent  desires  and 
actions.  The  desire  for  ceaseless  action  and  movement,  the  necessity  of 
immediately  exhibiting  in  action  all  that  passes  within  the  mind,  impels 
him  sometimes  merely  to  harmless  movements,  as  in  dancing,  speaking, 
singing,  shrieking,  laughing,  weeping,  etc.;  sometimes  to  restless,  ob- 


STATES    OF    MENTAL    EXALTATION.  197 

jectless  employment,  which  would  attempt,  according  to  the  caprice  of 
the  moment,  suddenly  and  impatiently  to  alter  everything  around,  some- 
times to  destroy  everything  animate  or  inanimate — a  tendency  which  may 
increase  to  outbreaks  of  the  blindest  fury  and  rage.  But  while  this  vio- 
lent and  unbridled  impulse  attacks  all  objects,  rushes  against  every  im- 
pediment, and,  totally  regardless  of  consequences,  shows  itself  in  eccentric 
and  aimless  actions,  we  nevertheless  find  in  many  of  these  patients  a  cer- 
tain cowardice  when  they  are  energetically  and  decidedly  resisted,  or, 
more  correctly,  a  state  of  anxiety  still  remaining  from  the  primary  period 
of  the  disease,  and  which  appears  not  only  to  have  originated  the  mania, 
but  also  to  maintain  it.  In  such  individuals  Ave  can  discover  no  reason- 
able act,  no  deed  deduced  from  any  rational  train  of  thought,  no  care  either 
for  their  own  or  their  family's  existence,  no  possibility  of  being  guided  by 
any  rational  principle;  indifference  towards  all  which  does  not  directly 
touch  upon  the  point  on  which  they  are  peculiarly  sensitive;  entire  want 
of  interest  in  anything  going  on  around;  loss  of  all  sense  of  decency, 
modesty,  and  propriety. 

The  concrete  mental  acts  which  show  themselves  with  such  violence 
consist  either  simply  in  certain  rapidly  changing  dispositions,  or  in  cer- 
tain sentiments  which  have  become  fixed,  and  obscure  groups  of  ideas 
which  manifest  themselves  in  some  particular  determinate  impulse. 
Thus  it  is,  that  in  consequence  of  a  morbid  exaggeration  of  the  sexual 
sensations,  frequently  arising  from  local  cause,  as  pruritus  pudendi  or 
ovarian  disease,  we  see  women  exhibiting  a  morbid  lasciviousness  which 
they  display  in  the  most  shameless  manner,  and  seek  to  gratify  by  the 
most  brutal  means.  The  desire  of  possession  may  show  itself  as  a  per- 
sistent propensity  to  collect  and  accumulate  everything,  or  as  a  moi-bid 
propensity  to  steal.  The  pleasure  in  loud  speaking,  in  the  rhythmical 
form  of  conversation,  in  noise-making,  in  spirituous  drinks,  in  satisfying 
their  appetite,  iu  shedding  blood,  etc. ,  may  show  itself  in  those  violent 
and  boisterious  ways,  and  there  result  fixed  or  transitory  conditions  which, 
according  to  the  predominance  of  this  or  that  particular  desire,  are  known 
under  the  name  of  nymphomania,  kleptomania,  logomania,  poiemata- 
mania,  dipsomania,  edodomania,  homicidal  mania,  etc. 

Quite  as  various  are  the  general  anomalies  of  the  self-sensation,  the 
morbid  dispositions  which  show  themselves  in  the  exalted  actions  of  the 
patient.  At  times  they  exhibit  a  sorrowful,  anxious,  sour,  angry,  defiant 
or  savage  disposition;  they  discover  a  great  pleasure  in  damaging  things 
and  doing  mischief,  and  are  exacting,  evil-disposed,  and  malicious. 
Sometimes,  again,  their  -disposition  is — and  this  is  quite  as  common  as 
the  foregoing — cheerful,  gay,  merry,  and  frivolous;  the  morbid  notion 
which  they  have  of  their  own  self-importance  displays  itself  in  a  bound- 
less hilarity,  in  a  feeling  of  liberty  and  good  fortune;  they  experience  a 
general  contentment  with  everything,  and  are  disposed  to  be  on  good 
terms  with  mankind  at  large. 

These  different  dispositions,  excitement  and  prostration,  overflowing 
contentment  and  the  utter  want  of  it,  alternate  frequently:  it  is  very 
common  to  see  maniacs  pass  suddenly  and  without  any  apparent  cause 
from  joy  to  sorrow,  from  defiance  to  shrinking  cowardice,  from  in- 
difference in  violent  reaction  to  furious  rage,  from  greedy  covetoitsness 
to  contentment,  from  anxiety  to  blind  confidence  and  temerity;  and  but 
rarely  does  an  external  moral  excitement  succeed  in  producing,  even  for 
but  a  short  time,  the  slightest  degree  of  calm  and  repose  in  this  state  of 
perpetually  changing  versatility. 


I 


198  STATES    OF    MENTAL    EXALTATION. 

Sometimes,  particularly  at  the  commencement  of  the  disease,  the  pa- 
tient himself  complains  of  this  necessity  to  commit  violent  deeds,  and  it 
may  be  possible  in  such  a  case,  by  reasoning  with  him,  or  by  some  strong 
mental  impression,  temporarily  to  restrain  him,  and  to  bring  him  again 
to  a  momentary  state  of  reason;  in  other  cases  it  seems  as  if  the  patient, 
in  a  state  of  semi-consciousness  of  his  condition,  gave  himself  up  to  the 
exaltation  when  it  has  once  begun,  and  gave  tlie  reins  to  the  thoughts 
whicli  beset  him;  it  seems  as  if  he  wished,  when  his  will  has  thus  got  loose 
and  is  no  longer  restrained,  to  revenge  himself  for  that  painful  restraint 
to  which  he  has  been  subjected  during  the  melancholic  stadium  of  his 
disease. 

Jacobi  has  very  properly  called  our  attention  to  the  wholly  impulsive  or  instinc- 
tive character  of  the  maniac's  acts.  That  which  determines  these  is  no  true  act  of 
volition — that  is,  the  transformation  of  a  dominant  idea  into  action,  with  a  cer- 
tain consciousness  of  the  object  to  be  attained,  and  of  the  means  necessary  to 
bring  it  about— and  as  little  is  it  a  state  of  profound  passion  which  stirs  the  patient 
into  action;  but  the  ever-running,  noisy  wheel  of  unrestrained  mental  movement 
busies  itself  merely  with  the  sensations,  the  vague  oscillations  of  thought  to 
which  men  have  given  the  name  of  feelings,  the  superficial  emotions,  the  num- 
berless momentary  and  accidental  sensual  excitements— these  it  is  which  alone 
have  any  influence  upon  him,  and  to  which  he  seeks  to  give  expression.  At  first 
the  patient  may  be  able  to  control  this  internal  tumult,  and,  what  is  sufficiently 
remarkable,  we  may  see  individuals  who,  when  chided  for  their  impropriety  of 
behavior,  calmly  reply,  not  without  a  certain  air  of  irony,  that  everything  is 
allowed  to  thera  since  they  are  fools.  The  furious  delirium  of  the  maniac  ap- 
proaches in  form  to  the  passion  of  anger,  but  it  does  not  spring  from  the  same 
motives  regarded  from  a  moral  point  of  view;  it  is  not  the  result  of  impressions 
made  upon  the  mind  of  ideas,  of  thoughts;  it  may  spring  up  quite  spontaneously, 
or,  on  the  other  hand,  it  may  be  determined  by  impressions  accidentally  produced 
upon  the  organs  of  sense,  as  by  the  light  of  the  moon  penetrating  into  a  room 
through  a  window— by  a  noise,  a  color,  the  sight  of  a  person  or  thing  which  has 
no  earthly  connection  with  the  patient:  any  of  these  may  be  sulficient  to  pro- 
voke it.  .    1 .   •  1     ,    T     1 

Scarcely  is  it  necessary  to  remark  here,  that  because  an  mdividual  displays 
certain  desires  or  dispositions  during  the  course  of  his  mania,  we  are  warranted 
in  concluding  that  he  may  exhibit  in  his  normal  states  similar  propensities  or 
mental  dispositions.  For  although  we  may  sometimes  see  certain  moral  pecuhar- 
ities  which  the  individual  habitually  presents  in  health  reproduced  in  his  manner  of 
conducting  himself  and  in  his  actions  during  his  disease  (e.  g.,  eccentricity,  capri- 
ciousness,  etc.),  yet  certain  it  is  that  the  character  becomes  entirely  changed:  the 
joyous  man  becomes  gloomy,  the  serious  man  gay,  the  virtuous  man  obscene, 
the  sober  man  a  drunkard,  etc.  Sometimes,  it  is  true,  certain  propensities  display 
themselves  for  the  first  time,  the  very  existence  of  which  we  had  not  even  before 
suspected,  and  of  which  we  believed  him  totally  ignorant;  as,  for  example,  when 
an  apparently  modest  girl  utters  obscene  language  which  she  could  not  possibly 
have  learnt  for  the  first  time  during  her  insanity. 

There  are  less  intense  cases  of  mania,  when  the  patient,  displaying  certain  pro- 
pensities, gives  himself  up  to  them  in  a  manner  wholly  regardless  of  propriety, 
but  which  still  present  veiy  transient  derangement  of  the  intellect,  where  one  is 
almost  inclined  to  believe  that  the  patient  voluntarily  indulges  his  evil  desires 
(kleptomania,  nymphomania,  dipsomania).  However,  what  shows  that  this  is 
truly  a  morbid  atfection,  is  the  involuntary  nature  of  these  acts;  the  patient  often 
complains  that  he  cannot  resist  the  desire;  and  further,  these  acts  have  some- 
thino-  instinctive  in  the  manner  in  which  they  show  themselves:  they  come  on  in 
fits  with  lucid  intervals,  they  are  frequently  accompanied  by  other  symptoms  of 
derangement  of  the  general  health,  and  tliey  frequently  come  on  after  a  preced- 
ing stage  of  depression.  Often  enough,  too,  this  state  passes  rapidly  into  one  of 
complete  and  unequivocal  mania. 

§  135.  2.  Anomalies  of  the  intellect.— The  first  and  most  important 
change  which  the  intellect  undergoes  in  mania,  consists  in  irritability 
and  quantitative  exaltation  analogous  to  that  of  the  disposition  and  the 


STATES    OF    MENTAL    EXALTATION.  199 

will— in  a  more  rapid  flow  of  ideas.  In  its  moet  moderate  degrees  this 
relation  appears  as  an  exaggeration  of  the  normal  faculty  of  thought. 
The  increased  development  and  rapid  succession  of  ideas  call  forth  a 
crowd  of  long-forgotten  remembrances  in  new  and  vivid  forms — there 
is  an  exaltation  of  memory  which,  in  some  cases,  presents  the  pecu- 
liarity that  the  maniac  is  able,  during  the  disease,  to  recite  correctly 
long  pieces  of  poetry,  which,  before  he  was  affected,  and  after  his  recovery, 
he  was  incapable  of  doing.  At  times,  also,  they  give  utterance  to 
thoughts,  combinations  of  ideas  and  opinions,  to  which  in  a  state  of 
health  they  never  could  lay  claim;  frequently,  according  to  the  humor  of 
the  moment,  or  stimulated  by  external  circumstances,  they  draw  curious 
comparisons, '  exhibit  a  spirit  of  the  most  biting  sarcasm,  express  them- 
selves with  extraordinary  eloquence,  and  hazard,  with  great  assurance, 
the  most  daring  opinions  formed  from  an  acute  observation  of  the  rela- 
tive circumstances. 

Such  occurs,  however,  in  only  the  minority  of  cases.  Generally,  from 
the  commencement,  or  at  least  very  soon,  the  quantitative  increase  and 
exaltation  of  thought  are  so  great,  that  there  results  a  restless  and  con- 
.stant  succession  of  isolated  ideas  which  have  no  intimate  relation  with 
each  other,  being  merely  connected  by  accidental  external  incidents,  and 
as  they  pass  through  the  consciousness  with  great  rapidity,  and  constantly 
change  their  combinations,  are  very  transitory  and  superficial,  or  of  a  very 
fragmentary  character.  These  ideas,  which,  owing  to  the  extreme  rapid- 
ity with  which  they  succeed  each  other,  are  very  imperfectly  developed, 
bear  the  impress  of  the  emotion  which  at  the  time  governs  the  patient, 
and  are  sometimes  lively,  supercilious,  and  extravagant;  at  others,  gloomy 
and  menacing.  They  are  in  part  provoked  and  their  contents  determined 
by  the  impressions  which  the  patient  receives  through  the  senses;  and 
these  impressions  themselves  are  often  falsified  by  hallucinations  and  illu- 
sions, or,  as  in  many  cases  of  delirium,  imperfectly  and  erroneously 
perceived,  owing  to  the  impression  being  only  partly  received  and  con- 
sidered. On  the  other  hand,  there  is  presented  to  the  perception,  from 
the  inward,  and  in  details  incomprehensible,  instinctive  action  of  the 
association  of  ideas,  a  countless  number  of  images,  words,  figures,  phra- 
ses, which  are  often  isolated  and  disconnected,  often  incessantly  and 
separately  repeated  in  cries  or  singing,  or  at  times  collected  together  into 
sentences,  phrases,  and  speeches  which  the  patient  utters  with  the  ex- 
pression of  the  emotion  dominant  at  the  time.  In  certain  cases,  the 
musical  element  of  speech  appears  as  a  tendency  to  rhythmical  expressions, 
to  assonance  and  rhyme:  the  patient  then  speaks  always  in  verses,^ 
which,  indeed,  contain  very  little  poetry,  being  merely  made  up  of  sim- 
ilarly sounding  sentences  and  words.  This  has  been  termed  "  rliyming 
delirium." 

The  principal  modification  or  anomaly  of  the  intelligence  in  confirmed 

1  We  have,  for  example,  observed  a  patient  who  cOuld  strikingly  delineate  any 
slight  resemblance  to  animals  in  the  physiognomies  of  those  ai'ound  hina. 
-'  Two  examples  of  this  : 

"  Und  es  ist  des  Himmels  Pflicht, 
Dass  man  Gott  ins  Herze  sicht. 

So  komm  in  den  Garten. 
Ei  lass  mich  nicht  warten. 
Der  Wein  schmeckt  mir  bitter. 
Schon  naht  des  Gewitter,"  etc. 
Bergmann,  *  Nasse's  Zeitschr.,'  1833,  ii.,  p.  419  ;  Jacobi,  '  Hauptformen,'  p.  540. 


200  STATES    OF    MENTAL    EXALTATION. 

mania  is,  then,  an  incoherence  of  ideas  which  is  the  inevitable  conse- 
quence of  the  precipitation  with  which  all  the  psychical  phenomena  are 
executed,  of  the  impossibility  of  the  complete  development  of  any  single 
perception,  of  the  rapid  emotional  changes,  and  of  the  fantastic  forms 
in  whicli  their  imagination  clothes  the  impressions  derived  from  the  or- 
gans of  sense.  Fixed  or  persistent  delirious  conceptions  are  not  proper 
to  this  condition,  neither  are  they  the  result  of  a  passionate  imagina- 
tion which  the  patient,  while  yet  in  good  health,  may  have  exhibited; 
although  often  enough  they  may  seem  to  warrant  us  in  coming  to  this 
conclusion;  as,  for  example,  when  a  maniac  often  manifests  traces 
of  former  mental  impressions,  we  may  be  led  to  believe  that  he  is  incess- 
antly occupied  Avith  certain  mental  causes  which  have  led  to  his  insanity. 
Here,  also,  the  possibility  of  a  rapid  change  in  the  ideas,  and  the  super- 
ficial character  of  the  entire  alienation  show  that  we  have  not  to  do  with 
persistent  dominant  ideas,  such  as  are  peculiar  to  states  of  profound 
emotion. 

But  this  is  not  to  say  that  temporary  delirious  conceptions  and  false 
ideas  cannot  be  present  in  mania.  On  the  contrary,  they  are  very  fre- 
quent. Sometimes  they  consist  in  series  of  false  opinions  regarding  the 
external  world,  such  as  must  necessarily  result  from  the  confused  ideas 
which,  half  developed,  urge  themselves  into  consciousness,  and,  in  their 
rapid  course,  often  resemble  fragments  of  abandoned  ideas  and  false  sen- 
sorial impressions.  Sometimes,  however,  delirious  conceptions  are  i^resent 
which  have  a  much  more  important  signification:  here,  also,  they  have 
again  essentially  the  significance  of  attempts  at  explanation  of  the  morbid 
disposition,  and  therefore  relate  only  to  the  special  ego.  A  haughty, 
audacious,  cheerful,  gay,  elevated  frame  of  mind — the  feeling  of  freedom 
of  action  and  exuberance  of  thought — call  forth,  according  to  the  law  of 
causality,  ideas  of  greatness,  possession,  riches,  great  moral  or  intellectual 
power,  etc.,  to  which  under  such  circumstances  alone  there  is  given  alike 
freedom  of  thought  and  volition.  The  exaggerated  idea  of  freedom  and 
power  must,  however,  have  a  foundation;  there  must  be  something  in  the 
ego  which  corresponds  to  it;  the  ego  must  for  the  moment  become  another; 
and  this  change  can  only  be  expressed  by  an  image,  Avhich  any  momen- 
tary thought  may  create.  The  patient  may  call  himself  Napoleon,  the 
Messiah,  God;  in  short  any  great  person.  He  may  believe  that  he  is  in- 
timately acquainted  with  all  the  sciences,  or  offer  to  those  around  him  all 
the  treasures  of  the  world.  He  may  also  select  characters  which  are  quite 
nonsensical:  for  example,  he  may  say  in  the  same  breath,  ''  I  am  Napo- 
leon," "I  am  this  chair,"  ''I  am  you,"  etc.  In  such  a  case,  he  either 
feels  that  he  cannot  fully  express  that  which  he  actually  desires  to  do, 
and  tries  to  make  up  for  this  by  an  accumulation  of  images;  or  he  at- 
tempts thus  vaguely  to  establish  a  great  omnipresence,  to  show  that  he  is 
in  everything,  which,  indeed,  is  in  accordance  with  his  exalted  frame  of 
mind. 

But — and  this  distinguishes  these  incoherently  combined  desultory 
delirious  ideas  from  those  of  the  following  form  (monomania) — none  of 
those  remain  fixed.  Every  temporary  excitation  brings  with  it  new 
images  and  ideas  which  dispel  the  old;  the  disposition  itself  is  changeable; 
and  as  each  frame  of  mind  passes  off,  no  explanation  is  necessary — the 
delirious  conceptions  have  no  time  to  develop  and  fix  themselves  by  at- 
tracting other  similar  ideas.  The  patient,  it  is  true,  frequently  gives  ex- 
pression to  these  ideas  in  a  loud  and  noisy  way,  but  never  in  a  tone  of  deep 
conviction;  indeed,  he  may  even  laugh  at  them.     Those  cases  present  a 


STATES    OF    MENTAL    EXALTATION.  201 

certain  relation  to  children  playing  a  comedy:  they  enter  entirely  into  the 
spirit  of  the  play,  and  actually  at  the  moment  consider  themselves  heroes, 
but  at  the  same  time  know  that  they  are  not  seriously  considered  such  by 
the  spectators. 

It  is  worthy  of  special  consideration,  that  in  many  cases  of  mania,  the  intellect 
— exclusive  of  the  disorders  we  have  just  mentioned — seems  to  be  very  slightly 
involved,  and  that  no  actual  weakness  or  diminution  of  it  is  apparent.  Fre- 
quently, in  spite  of  great  incoherence  of  ideas,  tne  remembrance  of  the  past 
is  not  only  perfectly  true,  but  in  many  cases  all  that  happened  during  the 
period  of  the  disease  is  even  well  remembered.  Not  unfrequently,  the  patient 
may,  by  an  appeal  to  his  recollection,  be  for  the  moment  withdrawn  from  the 
whirl  of  ideas,  and  enabled  to  answer  questions  concerning  his  former  life  cor- 
rectly, and  even  to  narrate  bygone  incidents.  Frequently,  he  understands  so  well 
all  that  passes  around  him,  and  has  so  much  control  over  himself,  that  a  friendly 
word,  a  threat,  or  a  joke,  or  even  an  appearance  of  confidence  in  him,  may  cause 
him  to  become  calm  for  the  moment.  The  perversions  of  the  judgment,  when 
they  do  not  actually  consist  of  the  forementioned  attempts  at  explanation  of  the 
disposition,  depend  inerely  upon  suppression,  as  if  from  want  of  time  suflficiently 
to  connect  the  transient,  fleeting,  incoherent  ideas ;  sometimes,  also,  from  the 
predominance  of  certain  series  of  perceptions  which  appear  to  the  patient  as 
definite  facts.  Thus  mania,  viewed  in  the  double  light  of  a  morbid  anomaly  of 
the  perception  and  of  the  will,  presents  the  same  general  character  of  an  affection 
of  the  mind  more  superficial  than  profound  ;  and  this  is  demonstrated,  above  all, 
by  the  possibility  of  the  sudden  appearance  of  a  lucid  interval,  and  even  of  rapid 
and  complete  recovery  after  the  disease  has  lasted  for  years — of  recovery  in  which 
the  patient,  although  his  mind  is  much  fatigued,  may  still  be  in  the  complete 
possession  of  the  former  range  of  his  intelligence,  and  in  every  way  the  same 
mentally  as  he  was  before.  Frequently,  also,  he  can  give  an  exact  account  of  his 
state  during  the  disease  ;  and  we  frequently  hear  such  individuals  give  vent  to 
expressions  like  the  following  statement  made  by  a  patient  of  Jacobi's :  "It  is 
actually  terrible  when  the  thoughts  so  run  into  one  another  in  one's  head." 

§  136.  3.  Anomalies  of  sensorial  function  and  of  movement. — Hallu- 
cinations of  sight,  of  hearing,  of  smell,  and  of  cutaneous  sensibility,  are 
sometimes  observed  in  mania,  and  not  unfrequently  they  cause  aggrava- 
tion of  the  symptoms.  Generally,  however,  they  are  of  but  little  imj)or- 
tance;  they  also  speedily  disajipear  in  the  giddy  haste  of  the  mental 
processes,  and  the  patient  cannot  give  them  any  prolonged  attention. 
Illusions  of  the  senses,  false  interpretations  of  sensorial  perceptions,  are 
much  more  frequent:  the  patient,  for  example,  takes  a  stranger  for  an 
old  acquaintance,  or  when  he  hears  any  noise  thinks  that  some  one  is 
calling  to  him.  False  judgments  in  this  case,  as  in  the  delirium  of 
fever,  ordinarily  depend  upon  non-consideration  of  certain  parts  of  the 
sensorial  impressions,  and  paying  great  attention  to  others,  and  upon 
superficial  similarities. 

There  is  also  sometimes  observed  an  exaggerated  sensibility  to  impres- 
sions of  sight  and  of  hearing.  Sometimes,  also,  there  is  dilatation  or 
contraction  of  the  pupils. 

As  to  the  organs  of  movement,  there  generally  exists  in  mania  a  con- 
tinual impulse  to  contractions  of  many  muscles.  The  movements  of  the 
body,  and  especially  those  of  the  organs  of  speech,  participate  in  the 
state  of  psychical  exaltation.  They  are  active,  rapid,  energetic,  inasmuch 
as  the  speech,  cries,  gesticulations,  and  actions  of  the  patient  all  tend  to 
outward  manifestation;  his  countenance  and  expression  are  lively,  intense, 
and  peculiar.  Much  has  been  said  of  the  extraordinary  strength,  of  the 
actual  increase  of  muscular  power  in  mania  (Esquirol,  Pinel,  Ideler,  etc.). 
In  the  vast  majority  of  cases  there  is  no  such  increase  of  strength;  the 
patient,  so  far  from  being  stronger  than  in  health,  can  be  easily  nuistered 
by  a  single  attendant,  and   the  appearance  of  increased  bodily  power 


202  STATES    OF    MENTAL    EXALTATION. 

generally  arises  merely  from  the  regardlessness  with  which  the  patient 
executes  muscular  movements  during  the  maniacal  attack.  On  the  other 
hand,  it  is  correct  and  very  remarkable  that  the  patients  can  continue, 
often /or  a  very  long  time,  to  make  use  of  their  muscular  power,  and  to 
an  extent  which  far  surpasses  their  capability  during  health.  Such  indi- 
viduals frequently  pass  whole  weeks,  and  even  months,  almost  without 
sleep,  a  j^rey  to  the  most  violent  fury;  and  the  possibility  of  such  enor- 
mous muscular  exertion  appears  only  explicable  by  the  assumption  that, 
owing  to  an  abnormal  state  of  the  muscular  sensibility,  the  patient  has 
no  feeling  of  fatigue.  We  see,  in  fact,  maniacs  in  whom  the  nutrition  is 
very  much  lowered,  thinking  and  declaring  that  they  are  very  strong,  and 
believing  themselves  capable  of  any  fatigue,  while  at  the  same  time  the 
great  emaciation,  and  the  exhaustion  which  succeeds  the  attack,  unmis- 
takably demonstrate  that  the  organism  cannot  bear  those  exertions  with 
impunity. 

Sometimes,  also,  actual  convulsions  are  observed  in  the  organs  of 
movement — grinding  of  the  teeth,  twitches  of  the  countenance,  or  more 
extended  convulsions,  the  latter  occurring  sometimes  during  waking, 
sometimes  during  transitory  fainting-fits  and  ecstatic  states.  Partial 
paralyses  are  much  more  rare  in  mania;  on  the  other  hand,  very  fre- 
quently the  first  commencement  of  general  paralysis  shows  itself  during  a 
moderate  attack  of  mania  by  the  uncertain  movements  of  the  tongue. 

Amongst  the  other  symptoms  of  mania,  troubled  uleep  is  very  common — in 
many  cases  persistent  complete  sleeplessness.  Again,  too  much  ought  not  to  be 
expected  from  a  calm  sleep  during  the  course  of  the  disease,  as  the  most  violent 
exacerbations  occasionally  ensue  after  the  quietest  nights,  and,  on  the  other  hand, 
even  convalescents  frequently  continue  for  a  long  time  to  complain  of  sleepless- 
ness. 

Anomalies  of  sensation  of  the  most  various  forms  may  present  themselves  in 
mania — lieadache,  vertigo,  heat,  aura-like  sensations  arising  from  the  chest,  ab- 
normal cutaneous  sensations,  pains  in  the  Umbs  real  or  apparent  (owing  to  indif- 
ference), insensibiUty  to  heat  or  cold ;  actual  anaesthesia  is  much  less  frequent 
than  was  formerly  supposed  (§  50). 

Ill  many  cases  there  is  observed  an  enormous  increase  of  the  appetite ;  and 
this  is  frequently  directed  to  uneatable  and  indigestible  things.  Absence  of  the 
feeling  of  satiety  appears  to  be  the  cause  of  this  voracity,  as  it  is  in  no  way  regu- 
lated by  the  degree  of  expenditure  of  muscular  force.  Not  unfrequently,  how- 
-ever,  the  demand  for  nutriment  is  not  at  all  heeded,  the  patient  quite  neglecting 
to  eat.  That  desire  to  eat  their  own  excrements,  which  sometimes  exists,  seems 
to  indicate  profound  perversity  of  taste  and  complete  absence  of  the  sentiment  of 
disgust. 

An  increase  of  the  sexual  instinct  forms,  in  many  cases,  the  centre-point  of  the 
morbid  ideas  and  efforts  ;  in  other  cases  it  is  only  accessory  and  moderate,  often 
it  is  entirelj'  absent.  It  is  manifested  by  obscene  language  and  writings,  in 
movements  of  the  hands,  exposing  the  person,  onanism,  etc.  On  the  whole,  it 
appears  to  occur  more  frequently  in  female  patients.  Irregularity  and  suppres- 
sion of  the  menses  exist  in  the  great  majority  of  cases :  their  re-establishment  has 
often  no  effect  upon  the  mental  state,  often  it  has  an  aggravating  influence  ;  at 
other  times  it  appears  coincidently  with  recovery. 

Changes  in  the  organs  of  circulation  and  digestion  are  not  alwaj's  present. 
Although  it  is  of  great  importance,  when  such  derangements  exist,  that  they 
should  be  minutely  investigated,  in  order  to  establish  the  indications  of  treatment 
in  individual  cases,  yet  they  are  of  little  importance  in  the  diagnosis  of  the  mania 
itself.  Then  the  pulse  is  sometimes  of  normal  frequency  and  fulness ;  it  is  seldom 
slower,  more  frequently  a  little  faster  than  usual,  and  rather  small  and  full. 
Nervous  palpitation  and  the  ordinary  signs  of  chronic  organic  heart-disease  are 
here,  as  in  mental  disease  generally,  of  only  ordinary  frequency.  According  to 
observations  made  in  the  asylum  at  Vienna,  the  heart-sounds  are  indistinct  during 
great  excitement,  and  become  again  clear  when  calm  sets  in.  It  is  not  uncommon 
to  see  considerable,  sometimes  very  great  cerebral  congestion,  redness  of  the  face 


STATES    OF    MENTAL    EXALTATION.  203 

and  heat  of  the  head.  It  is  only  exceptionally  that  the  countenance  is  pale ; 
sometimes  it  presents  a  cyanotic  hue  ;  the  eyes  are  sometimes  injected. 

In  the  vast  majority  of  cases  there  is  no  fever  present.  The  temperature  of 
the  body,  as  determined  by  the  thermometer,  is  normal  or  somewhat  diminished; 
it  is  only  during  the  maniacal  excitement  of  progressive  general  paralysis  that 
the  Ufemperature  of  the  body  is  said  to  be  increased.  (L.  Meyer,  '  Charite-Annalen, ' 
viii.,  2.) 

The  tongue  is  often  furred,  and  the  salivary  secretion  increased ;  the  patient 
seldom  complains  of  thirst,  except  where  it  is  caused  by  an  immoderate  desire  for 
alcoholic  liquors.  Frequently  the  bowels  are  irregular  and  constipated,  as  is 
usually  the  case  in  cerebral  diseases  generally. 

The  majority  of  maniacs  appear  emaciated,  notwithstanding  their  increased 
appetite.  Owing  to  this  and  to  the  tension  of  the  countenance,  they  appear  older 
than  they  actually  are.  The  diminution  of  the  nutrition  is  very  frequently  due 
to  former  morbid  states— anaemia,  febrile  diseases,  or  even  to  the  melancholia. 
Without  doubt,  however,  the  emaciation  may  also  be  owing  to  the  increased 
evolution  of  force  and  want  of  sleep  in  mania.  In  some  cases,  also,  it  is  the  result 
of  tuberculosis  or  of  some  other  serious  disease.  ;  There  are  innumerable  varieties 
of  these  accessory  symptoms,  the  result  of  former  or  existing  disease  of  other 
organs,  and  which  need  not  always  necessarily  be  closely  connected  with  the 
insanity. 

§  137.  As  to  the  invasion  and  course  of  mania,  it  is  observed  some- 
times as  a  pure  and  independent  form  of  mental  disease,  as  we  have 
hitherto  considered  it — as  a  stage  of  development  in  the  successive  series 
of  mental  disorders  ;  sometimes  transient  attacks  of  mania,  or  more  cor- 
rectly of  fury,  occur  in  individuals  who  are  already  subjects  of  profound 
mental  disease,  especially  in  all  the  various  forms  of  mental  weakness. 
These  attacks  are  frequently  owing  to  external  causes;  for  example,  to 
anger  :  frequently  also  they  are  caused  by  hallucinations.'  Here,  the 
characters  of  the  chronic  affections,  in  particular  the  weakness  of  the 
intellect,  are  always  combined  with  the  symptoms  of  the  acute  attacks. 
These  paroxysms  are  connected  with  those  convulsive  states  which  occa- 
sionally appear  during  the  course  of  paralysis. 

In  epileptics,  also,  it  is  not  uncommon  to  observe  attacks  of  mania 
which  are  often  characterized  by  a  high  degree  of  blind  fury  and  ferocity. 
Sometimes  they  immediately  follow  the  epileptic  attack,  as  if  the  excita- 
tion to  the  tumultuous  motory  movements  were  simply  transferred  to  other 
parts  of  the  brain. 

Anaemic  states  appear  to  predispose  more  to  the  outbreak  of  mania 
than  states  of  plethora.  Profuse  haemorrhage  (as  in  childbed,  menor- 
rhagia,  frequent  bleedings),  states  of  exhaustion  after  typhus  fever,  or 
after  rapidly  advancing  tuberculosis  or  prolonged  excesses,  may  in  many 
cases  be  recognized  as  proximate  or  predisposing  causes.  The  acute  menin- 
gitis of  adults  is  frequently  accompanied  by  a  delirium  which  resembles 
mania  in  every  respect ;  and  occasionally  there  is  afterwards  developed 
from  this  disease  a  more  chronic  form  of  mania. 

During  the  cottrse  of  mania  there  is  usually  an  alternation  of  reniissions 
and  exacerbations,  and  it  is  not  unusual  to  see  even  complete  remissions. 
Thus,  cases  have  been  observed  in  which  the  patients  during  entire 
months  were  only  maniacal  on  alternate  days,  with  completely  free  inter- 
mediate days — a  mode  of  cerebral  affection  in  every  way  analogous  to 
other  rhythmical  neuroses.  Very  often  an  exacerbation  occurs  during 
the  menstrual  period,  at  other  times  violent  paroxysms  and  remissions 
occur  without  any  appreciable  cause,  perhaps  in  consequence  of  changes 

•  Neumann  ('  Psychiatrie,'  p.  74)  remarks  that  these  attacks  of  fury  increase  in 
presence  of  others,  while  in  simple  mania  the  patient  generally  becomes  quieter 
on  the  entrance  of  the  physician  or  attendant. 


204  STATES    OF    MENTAL    EXALTATION. 

which  take  place  in  other  chronic  morbid  states  which  accompany  tlie 
mania ;  in  particular,  we  sometimes  see  complete  free  lucid  intervals  set 
in  quite  suddenly  and  unexpectedly. 

Melancholia  often  alternates  with  attacks  of  mania  ;  occasionally 
there  is  a  regular  (for  example,  at  certain  seasons  of  the  year)  alterna- 
tion of  exaltation  and  depression  {folie  circulaire  of  the  French  writers). 
In  these  cases  the  melancholic  stage  is  generally  somewhat  more  prolonged 
than  the  maniacal,  which  consists  rather  in  a  state  of  general  excitement 
and  restlessness  than  in  actual  mania.  At  other  times  we  see  attacks  of 
mania  occur  after  regular  or  irregular  lucid  intervals  every  one,  two,  three 
years,  etc. — iKriodkal  mania,  a  grave  form,  a  real  psychical  epilepsy 
which  shares  the  unfavorable  prognosis  with  ordinary  epilepsy  which  has 
become  habitual. 

Mildner  ('Psychiatr.  Corresp.  Bl  ,'  1857,  No.  17)  communicates  an  interesting 
case  where  an  individual  of  limited  intellectual  capacity,  with  insufficiency  and 
naurmur  at  the  aortic  valves,  in  consequence  of  a  violent  shock  fell  into  an  attack 
of  mania  which  lasted  for  only  an  hour  and  a  half,  and  returned  twice  or  thrice 
in  the  year.  The  very  transitory  maniacal  attacks  (mania  transitoria  of  very 
short  duration,  occurring  in  the  course  of  apparently  perfect  health)  may  be  all 
the  more  readily  compared  with  attacks  of  epilepsy,  as  sometimes  even  the  latter 
end  in  mania.  In  a  medico-legal  point  of  view,  it  is,  of  course,  quite  the  same 
whether  the  state  of  mania  during  which  the  crime  was  committed  was  of  long 
or  of  short  duration.  It  is  of  great  importance  to  know  that  undoubtedly  such 
quite  transient  attacks  actually  occur. 

The  single  paroxysms  of  mania  last  sometimes  only  a  few  hours, 
sometimes  entire  months  ;  frequently  there  is  observed  after  the  first  few 
weeks  a  considerable  remission.  Sometimes  it  appears  as  if  the  parox- 
ysms of  mania  constituted  a  sort  of  resolution  and  compensation  for  the 
former  state  of  mental  pain,  in  the  same  Avay  as  we  see  in  epilepsy  and 
hysteria  many  disagreeable  and  painful  sensations  which  precede  the 
attack  disappear  with  it.  Maniacal  attacks  which  are  mild  and  moder- 
ated by  remissions  may  last  for  many  years. 

It  is  a  well-known  fact,  that  very  often  during  the  course  of  mania 
the  symptoms  of  other  serious  diseases  are  arrested  in'  a  remarkable 
manner;  in  particular,  the  patients  seldom  or  never  complain  of  pain;  in 
phthisis  they  cough  very  little,  and  can  speak  and  cry  vociferously.  This 
is  not  to  be  considered  as  an  actual  arrest  of  such  organic  diseases;  on 
the  contrary,  they  continue  their  course  of  destruction  of  the  organ,  as 
is  shown  by  the  objective  symptoms;  but  an  anomaly  of  sensation  similar 
to  the  absence  of  the  feeling  of  fatigue  and  of  hunger  which,  combined 
with  the  patient's  absorption  in  this  delirium,  renders  him  little  liable  to 
subjective  impressions. 

Maniacs  may  recover  suddenly,  or  this  favorable  result  may  be  gradu- 
ally arrived  at  after  progressive  diminution  of  the  symptoms.  The 
excitement  ceases,  the  lucid  intervals  become  more  frequent  and  longer, 
the  behavior  becomes  gradually  more  orderly;  the  patient  again  inquires 
concerning  this  or  that  person,  experiences  ennui  and  tries  to  recover 
himself.  Sometimes,  also,  we  observe  that  the  cessation  of  the  mania  is 
coincident  with  the  appearance  of  some  other  disease;  for  example, 
intermittent  fever,  diarhoea,  skin  diseases,  furunculi,  etc.  We  ourselves 
have  in  certain  cases  observed  such  so-called  critical  appearances;  gener- 
ally, however,  they  are  absent;  and  the  statement  of  Esquirol,  that  no 
recovery  is  to  be  considered  permanent  which  is  not  accompanied  by  a 
well-marked  crisis,  appears  to  us  to  be  entirely  Avithout  foundation.  The 
most  trustworthy  symptom  of  recovery  is  the  return   of  the  former 


STATES    OF    MENTAX,    EXALTATION.  205 

desires  and  pursuits  of  the  patient,  and  of  his  unimpassioned  behavior 
a.nd  acknowledgment  that  he  is  really  ill.  We  have  on  several  occasions 
seen  the  observation  made  by  Jessen  very  strikingly  confirmed,  that  a 
relapse  is  especially  to  be  guarded  against  in  cases  where  the  (apparently 
calm)  patient  feels  remarkably  well,  and  speaks  wdth  exuberant  joy  of  his 
complete  recovery.  Even  those  who  are  completely  cured  are  always 
l^redisposed  in  a  high  degree  to  a  return  of  the  disease. 

In  individual  cases,  our  ojnnion  concerning  the  curability  of  the  dis- 
ease is  regulated  principally  by  the  symptoms  which  the  patient  presents 
of  more  or  less  presumable  organic  disease  of  the  brain.  Those  cases 
may  be  considered  absolutely  incurable  in  which  symptoms,  however 
slight,  of  general  paralysis  are  present  (see  §  4) ;  all  symptoms  of  jjersist- 
ent  convulsions  or  paralysis  in  the  extremities,  of  the  facial  nerve,  or  of 
the  pupils,  are  equally  unfavorable.  These  symptoms,  at  least  when 
they  are  not  quite  transitory — occurring,  for  example,  in  consequence  of 
temporary  but  violent  cerebral  congestion,' — appear  to  indicate  a  perma- 
nent extension  of  the  morbid  process  to  the  parts  situated  at  the  base  or 
in  the  centre  of  the  brain.  Indeed,  the  cerebral  hypertemias  which  are 
so  frequent  in  mania  may  occasion  the  development  of  exudations  and 
their  further  transformations.  The  more  the  disease  is  prolonged,  the 
less  it  is  interrupted  by  lucid  intervals  and  remissions;  and  tlie  more 
intense  the  hyperaemia,  the  more  these  exudations  are  to  be  feared.  The 
great  majority  of  recoveries  from  mania  take  place  within  a  year  from 
the  commencement  of  the  disease:  nevertheless,  cases  occur  where  recov- 
ery takes  place  after  the  disease  has  continued  for  six  or  seven  years, 
generally  with  radical  constitutional  changes  in  the  organism  of  the 
patient.  Great  violence  and  fury  in  the  attacks  are  in  no  way  unfavor- 
able in  regard  to  the  curability  of  the  disease,  no  more  than  violent 
hysterical  attacks  are  of  evil  omen  in  the  prognosis  of  hysteria.  Accord- 
ing to  all  the  observations  which  have  hitherto  been  made,  the  periodic 
intermittent  form  of  mania  must  in  general  be  considered  incurable. 

The  fact  that  in  many  cases  the  prognosis  depends  much  less  upon 
the  cerebral  disease  than  upon  the  presence  of  other  local  or  general 
affections — for  example,  phthisis,  great  anaemia,  hydraemic  or  scorbutic 
states,  etc. — requires  no  further  explanation.  Not  unfrequently,  conva- 
lescents from  mania  fall  into  a  condition  of  profound  bodily  and  mental 
weakness,  which  at  first  cannot  with  certainty  be  distinguished  from 
transition  into  dementia;  sometimes  the  disease  terminates  with  a  short 
stage  of  melancholia. 

When  the  patient  does  not  recover,  the  mania  may,  with  the  greatest 
outward  calm,  be  transformed  into  the  form  of  monomania,  or  may 
degenerate  into  one  of  the  chronic  secondary  states  of  mental  weakness 
— into  one  of  the  various  forms  of  dementia,  with  or  without  intervals 
of  agitation. 

In  mania,  death  may  result  from  the  cerebral  affection  itself,  in  con- 
sequence of  violent  hyperaemia  of  the  brain,  or  more  rarely  of  apoplectic 
extravations.  Frequently  the  patients  die  in  a  state  of  exhaustion,  with 
the  symptoms  of  collapse  (as  frequently  occurs  in  epilepsy),  in  conse- 
quence of  acute  or  chronic  disease  in  other  organs,  as  pneumonia,  pleurisy, 
carbuncle,  violent  intestinal  catarrh,  phthisis,  etc.  Accidents,  such  as 
leaping  from  a  window,  etc.,  are,  in  this  form  of  insanity,  not  unfre- 
quently the  cause  of  death. 


See  the  chapter  on  "  Pathological  Anatomy." 


206  8TATES    OF    MENTAL    EXALTATION. 

Example  XXXII. — Simple  mania,  ivith  sexual  excitem,ent  and  cleptomania ; 
recovery. — Gottfried  Demons,  aet.  22,  of  delicate  constitution.  During  childhood 
he  liad  been  been  frequently  affected  with  eruptions  of  the  scalp  :  his  character 
is  peculiar,  and  his  intellect  weak.  His  maternal  grandmother  had  been  insane 
for  seven  years,  and  he,  at  tlie  age  of  nineteen,  fell  into  a  state  of  melancholy, 
which,  imder  the  use  of  remedies,  disappeared  in  three  months.  At  twenty-one, 
he  suffered  for  some  time  from  obstinate  constipation  and  vomiting.  In  May, 
1811,  on  reading  the  narrative  of  a  traveller,  he  felt  himself  deeply  affected  by  the 
hardships  which  that  individual  had  had  to  endure.  The  following  day  he  com- 
plained of  being  ill  at  ease,  and  an  emetic  was  administered  to  him.  Two  days 
after,  the  patient  was  seized  by  an  attack  of  persistent  fury  and  incoherent  talk 
(large  doses  of  tartar  emetic  and  purgatives).  During  the  fifteen  days  which  fol- 
lowed, he  had,  at  different  times,  lucid  intervals  of  several  hours'  duration,  but 
they  were  always  succeeded  by  an  attack  of  fury.  Nevertheless,  these  attacks 
gradually  diminished  in  intensity  ;  towards  the  middle  of  June  they  became  more 
rare,  and  the  patient  chatted  continually  from  morning  to  evening.  During  the 
night,  however,  he  enjoyed  several  hours  of  calm  sleep.  The  pulse  was  tranquil ; 
the  countenance  worn  ;  the  appetite  increased  ;  the  bowels  constipated.  At  times 
some  slight  convulsive  movements  '"ere  observed  in  the  limbs. 

A  month  after  the  commencement  of  the  illness,  the  patient  was  taken  to 
Siegburg.  During  the  first  ten  days  which  followed  his  admission,  he  remained 
in  a  state  of  constant  delirium  and  incoherency,  and  exhibited  a  tendency  to 
commit  acts  of  violence  on  those  who  suiTounded  him.  Nevertheless,  it  was 
generally  during  the  day  that  he  had  his  attacks  of  fury,  and  during  the  night  he 
had  generally  several  hours  of  calm  slumber.  Although  during  the  paroxyms  he 
indulged  constantly  in  violent  movements,  the  pulse  never  rose  above  from  70  to 
80.  The  temperature  of  the  body  was  almost  normal ;  the  tongue  was  clean  and 
moist ;  the  patient  spat  often  ;  the  stools  were  costive.  Towards  the  end  of  July, 
the  intensity  of  the  maniacal  attacks  diminished,  although  the  invalid  was  always 
a  prey  to  a  certain  state  of  excitement  and  extraordinaiy  confusion  ;  he  talked 
nonsense  tlie  whole  day,  but  his  ideas  had  not  the  least  connection,  and  no  trace 
of  a  dominant  idea  could  be  found  in  his  talk.  He  was  still  dirty,  and  attacked 
his  food  with  brutal  gluttony,  etc.  The  nights  were  generally  calm  ;  the  pulse 
and  the  temperature  of  the  body  continued  almost  normal  (extract  of  belladonna 
for  four  weeks  ;  then  tincture  of  digitalis  from  the  beginning  of  October  to  the 
end  of  December).  Under  the  influence  of  the  latter  remedy,  the  pulse  fell  some- 
times to  50.  In  the  carotids  it  was  fuller  and  more  tense  than  formerly.  The 
patient  had,  from  time  to  time,  a  tendency  to  epistaxis.  On  the  other  hand,  it 
was  tlien  observed  that  he  had  an  excitement  of  the  genital  organs  which  had 
not  been  before  observed.  He  attacked  all  the  maid-servants  whom  he  saw,  and 
indulged  in  onanism  without  shame.  Otherwise,  from  a  psychical  point  of  view 
his  state  had  changed  very  little,  except  that  from  th3  end  of  October  he  was 
somewhat  less  confused  in  judgment ;  but  the  emotional  perversion  had  rather 
augmented,  and  he  exliibited  a  manifest  disposition  to  steal — an  inclination  which 
had  never  been  observed  in  him  while  in  health.  From  time  to  time  he  still 
suffered  some  paroxyms  of  maniacal  excitement,  which  again  necessitated  the 
use  of  the  strait-jacket  to  prevent  him  from  committing  acts  of  violence. 

At  the  commencement  of  January,  the  use  of  these  remedies  was  stopped. 
Every  two  days  the  patient  received  a  douche  of  twenty  buckets  of  cold  water 
poured  on  the  head  ;  and  every  week  three  leeches  were  applied  to  the  nostril. 
He  now  improved  in  a  surprising  way.  By  the  end  of  February,  he  could  answer 
correctly  aU  simple  questions.  The  attacks  of  maniacal  excitement  completely 
disappeared,  as  well  as  the  disposition  to  steal  and  the  venereal  tendencies.  After 
a  short  time  his  intellect  was  restored ;  his  conduct  became  regular.  He  quitted 
the  asylum  in  July,  after  having  spent  a  year  in  it.  (Jacobi,  '  Die  Hauptformen,' 
i.,  1844,  p.  81). 

Example  XXXIII.— ilforaZ  causes ;  mania  unth  tendency  to  derision,  nym- 
phomania {prurigo  pudendi).  Recovery. — Catherine  J — ,  a?t.  i>9,  without  any 
hereditary  tendency  to  insanity,  enjoying  good  health,  exhibited,  while  quite  a 
young  girl,  deeply  rehgious  feelings,  at  the  same  time  a  very  amorous  disposition. 
She  married  one  of  her  near  relatives,  after  having  had  a  child  by  him.  After  a 
year  and  a  half  she  lost  her  husband.  He  was  very  rich,  and  had  often  lent 
money,  taking  securities  for  it  upon  property,  which  forthwith  he  caused  to  be 
sold  and  bought  in.  He  was,  accordingly,  universally  hated  ;  and  it  used  to  be 
said,  after  his  death,  that  on  several  occasions  he  had  been  seen,  during  the  night, 
in  the  form  of  a  phantom  of  fire,  passing  over  the  lands  which  he  had  thus 


STATES    OF    MENTAL    EXALTATION.  207 

bought.  Catherine  was  greatly  alarmed  by  this  report,  to  which  she  was  ready 
to  give  credence.  She  fell  at  first  into  a  state  of  agitation  and  anxiety,  brooding 
over  a  thought  which  had  troubled  her  before,  namely,  that  by  reason  of  her  near 
relationship  to  her  husband,  the  marriage  which  she  had  contracted  with  him 
was  nothing  but  a  concubinage,  and  that  the  phantom  nad  come  to  reproach  her 
with  the  crime,  as  well  as  witli  the  property  which  her  husband  had  acquired  by 
his  forced  sales.  She  then  conceived  the  idea  of  restoring  these  possessions  to 
their  former  owners  ;  she  examined  conscientiously  the  titles  of  the  property,  and 
the  means  by  which  her  husband  had  gained  his  fortune.  She  obtained  in  tliat 
way  the  proof  that,  as  far  as  she  was  concerned,  the  property  had  been  legally 
acquired  :  but  that  gave  her  not  the  least  tranquillity;  the  apparition  of  lier  husband 
under  the  form  of  a  spectre  of  fire  was  always  present  to  her  mind.  She  remained 
calm,  silent,  and  cold  before  company;  her  eyes  remained  fixed  on  the  same 
point.  She  saw  and  heard  nothing,  save  the  profound  restlessness  which  tor- 
mented her  within.  This  state  of  things  continued  for  about  two  months,  when 
she  became  agitated,  unable  to  remain  at  home,  coming  and  going  to  and  fro. 
Then  she  set  out  to  go  to  her  friends  at  Riedelheim.  When  she  arrived,  she  gave 
herself  up  to  a  perfect  extravagance  of  politeness  and  of  compliments,  expressing 
herself  with  extraordinary  elegance  ;  then,  on  the  following  night,  she  began  to 
cry  out  "  Fire  !"  came  in  in  extreme  terror,  and  tore  her  garments  (bloodletting, 
cold  application,  clysters,  etc.). 

I  was  then  called  in.  When  I  entered  her  room  with  one  of  her  neighbors — a 
man  of  dry  manners  and  very  little  given  to  compliment,  who  had  a  long  nose, — 
she  advanced  towards  me  in  a  friendly  way,  asked  how  I  did,  and  made  me  a 
profound  bow.  Then  she  turned  several  times  on  her  left  foot  and  burst  into 
laughter.  Her  neighbor  observed  to  her  that  it  was  unbecoming  to  behave  in 
that  fashion  before  the  doctor.  ' '  Idiot ! "  she  answered, ' '  ask  the  doctor  to  help 
you  to  comprehend;  you  might  reach  it  with  your  long  nose."  She  then  began  to 
cry  out,  and  to  call  him  names,  and  wished  to  bite  him.  He  got  out  of  the  way. 
She  then  leapt  with  great  adroitness  on  the  couch,  and  from  that  on  the  foot  of 
the  bed,  where  she  began  to  dance  like  a  rope-dancer.  She  sang,  wept,  and 
laughed  by  turns.  She  never  ceased  to  talk  foolishly,  flashing  out  ideas  quite 
incoherent  and  without  connection,  and  which  were  without  meaning,  except 
that  she  was  enraged.  She  seemed  a  satyi".  At  the  door  there  was  an  opening 
through  which  she  could  see  into  the  street.  Upon  all  who  passed  in  front  she 
made  wicked,  although  partially  true,  observations,  relative  to  the  bad  side  of 
their  character,  or  to  ridiculous  incidents  in  their  lives.  At  times  she  ran  from 
one  corner  of  the  room  to  another,  as  if  she  were  scared  by  something;  again  she 
would  make  violent  and  rapid  movements  of  the  right  arm,  as  if  she  struggled 
with  a  spectre;  but  she  never  had  a  moment's  rest.  The  face  was  pale,  but  when 
the  patient  was  furious  it  became  red.  The  veins  of  the  brow  became  swollen 
like  a  quill;  the  eyes  injected;  the  lips  red;  the  countenance  menacing;  all  the 
muscles  tense.  She  tore  her  dress;  knocked  on  the  window,  and  scraped  the 
walls.  She  had  an  enormous  appetite,  and  ate  voraciously  the  food  that  was 
given  to  her.  She  made  water  and  went  to  stool  without  concerning  herself 
whether  any  one  was  near. 

By  night  she  slept  for  only  a  few  hours;  immediately  when  the  rays  of  the  sun 
appeared  she  was  again  agitated.  Her  menstruation  was  regular;  at  the  time  of 
her  courses  the  paroxysms  were  most  intense.  Whenever  ideas  having  any  con- 
nection came,  they  were  biting  sarcasms.  She  named  her  guardian  Monsieur 
Robespierre,  and  she  added,  "In  German,  that  means  M.  the  valet  of  the  execu- 
tioner." After  a  few  coherent  thoughts,  there  came  all  at  once  an  uninterrupted 
flow  of  words  completely  devoid  of  sense;  although  sometimes  amid  this  confused 
nonsense  there  might  be  distinguished  some  ideas  relating  to  maternal  love. 

She  continued  in  this  condition  during  several  months;  then  I  was  again  asked 
to  visit  her.  I  found  her  in  the  following  state:— Except  sight  and  hearing,  the 
other  senses  were  gone.  She  was  nymphomaniac  in  a  high  degree;  rubbing  the 
genital  organs,  swearing  at  her  unsatisfied  desires;  asking  for  men,  etc.,  etc.  All 
this  formed  an  assemblage  of  symptoms  which  could  not  be  mistaken. 

I  subjected  the  patient  to  prolonged  walks  along  unfrequented  roads;  and 
when  she  had  a  violent  attack  of  fury,  I  gave  her  50  drops  of  the  distilled  water 
of  bitter  almonds  concentrated.  The  fury  ceased  immediately.  The  patient  sank 
down  on  a  mattress  which  was  beside  her.  and  remained  calm.  But  at  the  end 
of  two  hours  the /wror  wferwrns  returned,  the  patient  believing  that  she  saw  in 
every  man  an  old  lover  (distilled  water  of  almonds,  50  to  150  drops,  three  times  a 
day).    The  sense  of  touch  and  of  taste  seemed  to  return  somewhat;  the  patient 


208  STATES    OF    MENTAL    EXALTATION. 

talked  a  little,  although  very  vaguely,  of  her  children,  but  she  always  thought 
she  saw  her  lovers  around  her.  The  attacks  of  mania  became  shorter  and  more 
rare;  the  patient  obtained  a  little  more  sleep,  and  remained  also  more  calm  in  bed. 
We  could  already  suggest  to  her  the  memory  of  certain  important  circumstances  in 
her  life.  When  she  took  to  raillery,  that  generally  betokened  the  near  approach 
of  an  attack  of  fury;  and  when  her  raillery  became  refined  and  intellectual  we 
might  count  on  the  certain  approach  of  an  attack.  She  did  not  any  longer  tear 
her  dress,  but,  on  the  contrary,  she  liked  to  attire  herself  neatly;  she  no  longer 
spoiled  articles  except  at  rare  intervals,  and  the  least  repremand  was  enough  to 
cause  her  to  conduct  herself  becomingly.  As  in  the  case  of  children,  it  was  neces- 
sary to  resume  her  education  at  the  first  elements,  and  to  lead  her  progressively 
to  a  higher  stage.  But  the  attacks  of  furious  delirium  did  not  yet  altogether  cease. 
In  the  mterval  of  the  occasions  when  she  took  her  medicine  (water  of  bitter 
almonds),  and  ordinarily  two  hours  after  having  taken  it,  she  was  seized  by  an 
attack  of  fury  and  an  immoderate  desire  of  coition.  Fifteen  days  after  each 
menstrual  period,  little  bleedings  of  ten  ounces  were  taken  from  her.  From  that 
time  the  attacks  of  delirium  became  rarer,  and  the  patient  began  to  complain  of 
itching  and  heat  in  the  genital  organs.  Then  gradually  the  patient  was  induced 
to  work.  Good  example  and  good  counsel  led  her  back  to  religions  convictions, 
and  she  was  at  length  cured  after  a  year's  illness.  (Velten  in  Nasse's  'Zeit- 
schrift,'  1820,  p.  709.) 

Example  XXXIV.— Two  attacks  of  mania,  each  after  strong  impressions  of 
smell  during  confinement  and  nursing;  a  third  attack  after  a  premature  birth. 
Recovery. — R— ,  set.  34,  was  admitted  to  the  asylum  on  the  10th  November,  1813. 
She  is  of  soft  temperament,  but  very  sprightly;  tall;  hair  of  chestnut  color;  eyes 
large  and  brown.  At  sixteen,  menstruation  set  in  without  difficulty ;  at  twenty- 
four,  R —  was  manied. 

In  her  twenty-sixth  year,  three  days  after  her  first  confinement,  a  lady  perfumed 
with  musk  came  to  see  her.  Immediately  she  became  delirious;  nevertheless, 
she  continued  to  suckle  her  infant,  which  died  at  three  years  of  age.  This  first 
attack  was  characterized  by  mania  with  fury,  and  lasted  only  two  months.  It 
ceased  suddenly  after  a  sudden  fright.  Since  this  first  attack,  thi^  woman  has 
continued  very  susceptible.  Every  spring  she  was  subject  to  exaltation  unaccom- 
panied by  delii-ium,  which  was  dispelled  by  the  use  of  antispasmodics. 

In  her  tliirtieth  year,  while  R — weaned  her  infant  at  the  age  of  one  year,  she 
went  to  the  shop  of  a  man  where  there  was  painting.  The  smell  immediately 
excited  delirium,  which  increased  during  five  days,  and  was  succeeded  by  inania 
with  fury.  On  the  fourth  of  August,  1809,  she  was  admitted  to  the  Salpetriere. 
Very  marked  abatement;  R —  is  calm,  and  seems  in  possession  of  her  reason.  Her 
husband  solicits  her  dismissal,  and  obtains  it  on  the  12th  October  following. 
From  the  second  day  after  her  dismissal,  return  of  delirium,  of  mania;  stoppage  of 
menstruation;  abdomen  swollen.  Returned  to  the  asylum  the  patient  becomes 
quiet  on  the  approach  of  winter.  In  December,  the  courses  are  re-established, 
and  R —  leaves  the  asylum  June,  1811. 

In  her  thirty-fourth  year,  1st  November,  1813,  premature  birth  at  two  months; 
haemoiThage.  From  the  second  day,  great  talkativeness.  3d  November,  mania, 
fury';  the  patient  is  taken  to  the  asylum.  On  her  arrival,  her  eyes  are  haggard; 
her  face  pale;  look  abashed;  general  raving;  mania,  fury.  Three  days  after,  she 
is  calm,  and  recognizes  the  fact  that  she  is  in  the  asylum. 

On  the  16th  November,  the  courses  cease.  The  patient  sees  her  husband  with 
evident  interest;  she  is  sad,  but  her  answeres  are  accurate.  On  the  28th,  fever; 
gastric  oppression;  copious  ejection.  Since  that  time  her  ideas  are  connected;  R— 
is  calm,  and  engages  in  work;  gradual  return  to  reason. 

On  the  21st  December,  R—  leaves  the  asylum  quite  sane;  although  the  courses 
are  not  perfectly  re-established.  (Esquirol,  translated  by  Bernhardt,  i.,  1838,  p. 
152.) 

Example  XXXV.— Paroxysms  of  fury,  accompanied  by  attempts  at  murder, 
coming  in  the  place  of  epileptic  attacks.— A  peasant,  born  at  Krumbach  in  Swabia. 
whose  parents  did  not  enjoy  the  best  health,  set.  27,  and  unmarried,  was  subject 
from  his  eighth  year  to  epileptic  attacks.  Two  years  ago,  his  disease  changed  its 
character  without  any  one  being  able  to  account  for  it;  and  in  place  of  epileptic 
attacks,  the  man  found  himself  seized  by  an  irresistible  disposition  to  commit 
murder.  He  feels  the  approach  of  the  fit  several  hours,  and  sometimes  a  day, 
before  it  conies  on.  Immediately  when  he  has  the  presentiment,  he  earnestly 
asks  to  be  tied  up  and  boimd  with  chains,  lest  he  commit  some  crime.  "  When 
it  takes  me,"  he  says,  "I  must  kill— I  must  strangle,  were  it  only  an  infant." 


STATES    OF    MENTAL    EXALTATION.  209 

His  mother  and  father,  whom,  for  all  that,  he  loves  dearly,  were  the  first  victims 
of  these  fits:  "  Mother,"  cried  he,  in  a  loud  tone,  "  save  yourself  or  I  must  strangle 
you." 

Before  the  fit,  he  complains  of  being  overpowered  by  sleep,  and  yet  without 
being  able  to  sleep.  He  feels  himself  greatly  exhausted,  and  experiences  slight 
convulsive  movements  in  the  limbs.  During  tlie  fit,  he  retains  the  consciousness 
of  his  own  existence,  and  knows  pei'fectly  that  in  committing  murder  he  is  guilty 
of  a  crime.  When  he  has  been  placed  beyond  the  reach  of  doing  harm,  he  makes 
contortions  and  frightful  grimaces,  sometimes  singing,  and  sometimes  speaking 
in  verse.  The  fit  lasts  from  one  to  two  days.  When  it  is  over,  he  cries,  "  Unloose 
me.  Alas  !  I  have  suffered  greatly ;  but  I  have  got  out  of  it  well,  since  I  have 
killed  no  one."    (Esquirol,  von  Bernhardt,  ii.,  p.  371.) 

§  138.  More  minutely  to  describe  the  various  forms  of  mania  repre- 
sented by  authors  would  be  of  no  special  interest.  They  are  arranged,  as 
we  have  ali'eady  indicated  in  a  former  paragraph,  partly  according  to  the 
various  tendencies  and  desires  which  manifest  themselves  in  a  prominent 
manner  (nymphomania,  mania  saltans,  furor  poeticus,  etc.),  partly 
according  to  the  various  causes  of  the  disease  (mania  puerperalis,  parturi- 
entium,  potatorum,  etc.).  As  to  the  latter  form,  delirium  tremens,  in  all 
cases  in  which  it  is  well  marked,  it  consists  in  a  generally  moderate  degree 
of  mania,  which  is  likewise  almost  always  preceded  by  a  short  stage  of 
melancholia,  and  with  which  there  are  ordinarily,  at  the  same  time, 
present  some  degree  of  stupor,  trembling  of  the  limbs,  persistent  sleep- 
lessness, and  copious  perspiration.  Frequently  a  state  of  anxiety  is  pres- 
ent during  the  whole  maniacal  period,  and  keeps  up  the  excitement;  very 
frequently  there  ar^  also  hallucinations  of  sight  of  the  most  varied  de- 
scription, which  in  the  great  majority  of  cases  consist  of  phantasms  of 
animals,  mice,  horses,  birds,  etc. :  the  delirium  also  turns  upon  various 
other  illusions  and  phantasms  of  a  predominantly  sad  and  anxious 
nature. 

We  shall  not  here  enter  into  details  regarding  deliriuvi  tremens.  It  is  not 
usually  classed  amongst  mental  diseases,  and  owing  to  its  short  duration  is  not 
often  met  with  in  asylums.  Nevertheless,  the  institutions  of  large  towns  are 
constantly  liable  to  receive  a  number  more  or  less  considerable  of  these  cases;  their 
statistics  are  on  that  accoimt,  as  compared  with  other  asylums,  essentially  modi- 
fied (much  more  favorable).  Of  322  delirium  tremens  patients  admitted  into  the 
Bloomingdale  Asylum  at  New  York,  20  died,  286  recovered,  and  16  were  still 
under  treatment:  the  fatal  issue  occurred  generally  within  the  first  week.  (P. 
Earle.) 

The  nymjihomaniaeal  states,  ^.  e.  those  of  increased  sexual  excitement  in  the 
female  sex.  do  not  always  manif3st  themselves  by  an  open  expression  of  the  sex- 
ual excitation;  more  frequently  they  assume  a  milder  form,  such  as  flirting,  love 
of  dress,  freedom  of  conversation  and  a  certain  familiarity  with  the  physician, 
much  talking  about  marriage,  little  equivocations,  etc.  We  frequently  observe 
in  women  affected  with  this  form  of  mania,  a  constant  desire  to  wash  the  body, 
to  comb  the  hair,  to  destroy  their  clothes,  to  spit  at  people,  to  scold  the  female 
attendants,  to  suspect  other  women  in  a  sexual  respect.  (See  Neumann,  '  Psy- 
chiatrie,'  p.  79.)  These  states  often  last  for  a  long  time.  Finally,  mania  with  the 
character  of  nymphomania  sometimes  assumes  the  form  of  an  acute  affection, 
leading  rapidly  to  exhaustion  and  death:  in  these  cases  there  is  generally  acute 
inflammation  of  the  internal  organs  of  generation.  (L.  Meyer,  Virchow's '  Archiv,' 
ix.,  1856,  p.  98.) 

Those  cases  which  several  French  observers  (particularly  Brierre)  have 
described  under  the  title  of  acute  delirium  (delire  aigu),  appear  to  merit 
being  distinguished  as  a  special  form  of  mania,  and  to  demand  further 
investigation.  These  cases  are  characterized  by  the  rapidity  of  their  out- 
break; by  furious  delirium  with  incessant  incoherent,  senseless  chattering, 
but  with  the  dominant  expression  of  anxiety,  and,  frequently,  ideas  of 
14 


210  STATES    OF    MENTAL    EXALTATION. 

being  poisoned;  by  vertigo,  awkard  trembling  movements,  as  if  the  patient 
were  half  intoxicated;  frequently,  slight  muscular  contractions,  sleepless- 
ness, paleness  of  the  countenance,  dry  tongue,  rapid  exhaustion.  Accord- 
ing to  Bierre,  these  states  are  often  accompanied  by  fever;  they  last  from 
a  period  of  from  several  days  to  six  or  eight  weeks,  they  often  terminate 
fatally  through  sudden  collapse;  after  death,  hypertemia  of  the  cerebral 
membranes,  or  nothing  at  all,  is  found. 

Cruveilheir  and  Abercroniby  have  already  described  such  cases.  See  Brierre, 
'Union  Medicale,'  1849,  and  '  Memoires  de  1' Academic  de  Medecine,'  torn.  xi.  ; 
Luther  Bell,  '  Amer.  Journal  of  Insanity,'  1849  ;  Jensen,  '  Zeitschrift  f.  Psychia- 
trie,'  xi.,  1854,  p.  616. 

§  139,  The  frequent  states  of  incompletely  developed  mania  are  of  great 
practical  importance;  in  the  majority  of  cases  they  represent  the  first 
stage  of  exaltation  which  precedes  the  outbreak  of  mania  or  of  monomania, 
or  a  period  of  remission  between  two  maniacal  attacks,  or  even  a  stage  of 
termination  of  mania.     Occasionally,  however,  this  state  continues  for  a 
long  time  in  the  same  manner,  and  it  may  then  very  properly  be  con- 
sidered as  a  special  form  of  insanity  with  tlie  character  of  exaltation.     We 
have  already  in  part  made  mention  of  this  state  as  a  relatively  mild  mode 
of  expression  of  certain  desires  and  instincts,  while  the  patient  still  shows 
no  striking  disorder  of  the  intelligence.     Frequently,  however,  there  is. 
also  observed  a  general  increase  of  volition  not  concentrated  upon  a  defi- 
nite series  of  objects;  and  this  is  manifested  as  an  uncommon  and  incon- 
stant activity  and  restlessness,  as  an   ardent    desire  always  to  begin 
something  new,  as  a  necessity  to  alter  and  remodel  the  external  world 
according  to  eccentric  projects.     Such  patients  have  always  something  to 
do — speculations  to  enter  into,  to  buy  or  to  sell,  to  present,  to  build,  etc. ;, 
all  they  see  or  which  happens  to  them  they  would  have  and  possess,  and 
very  often  they  thereby  spend  large  sums  in  a  very  sliort  time.     Ordi- 
narily, they  are  very  vain,  show  a  desire  to  be  considered  great  and  to 
excite  admiration;  their  demeanor  is  confident  and  arrogant:  the  humor 
generally  changes  rapidly  from  joy  and  frolick  to  depression,  and  again 
to  violent  outbreaks  of  anger,  the  latter  especially  when  their  actions  are- 
opposed  and  their  pride  hurt.     Some  show  a  tendency  to  cunning  and  in- 
trigue— others  a  desire  to  steal,  to  drunkenness,  erotic  tendencies,  expan- 
sive religious  ideas.     The  patients  generally  talk  a  great  deal,  loud  and 
rapidly,  but  without  special  delirium;  their  discourse  shows  that  they 
have  an  exaggerated  idea  of  self,  but  without  the  delusion  of  being  some 
other  illustrious  person;  they  have  merely  a  tendency  to  estimate  to  the 
utmost  their  faculties  and  powers — their  wealth,  then-  physical  strength, 
health,  or  figure.     The  high  estimate  which  the  patient  has  of  himself 
frequently  extends  to  all  that  belongs  to  him,  and  the  mere  fact  of  any- 
thing being  in  his  possession  is  perfectly  sufficient  to  endow  it  with 
extraordinary  qualities. 

In  this  description,  given  from  actual  observation,  and  which  agrees 
with  that  of  Jessen,'  there  will  be  recognized  a  state  of  moderate  exalta- 
tion, which,  when  the  explosion  of  the  effort  takes  place  towards  the  ex- 
terior, becomes  mania;  when  the  increase  is  more  internal,  and  fixed 
delirious  conceptions  are  developed,  becomes  monomania.  The  further 
his  condition  is  from  one  of  these  evident  characteristic  forms — that  is, 
the  less  the  patient  is  delirious,  the  more  is  he  in  a  state  to  justify  his. 

^Art.  "Moria,"  '  Berl.  Encycl.  Worterbuch,'  Bd.  xxiv.,  p.  127. 


STATES    OF    MENTAL    EXALTATION.  211 

morbid  tendencies  by  reasons  which  still  lie  within  the  bounds  of  possi- 
bility, and  do  not  yet  appear  to  be  decidedly  the  result  of  insanity— the 
more  easily  will  tlie  morbid  nature  of  his  state  be  overlooked  and  con- 
founded with  the  result  of  the  normal  tendencies  of  a  capricious  and 
original  individual.  He  then  falls  under  the  category  oifolie  raisonnante, 
of  which  this  constitutes  the  maniacal  form. 

Should  the  affection  remain  at  the  stage  of  development  which  we 
have  described,  it  may  either  terminate  (after  a  short  duration)  in  re- 
covery, or  pass  into  a  state  of  mental  weakness  m  which  the  dominant 
joyous  self-satisfied  and  self-contented  humor  becomes  fixed,  and  mani- 
fests itself  in  silly,  foolish  acts  and  desires— laughing,  dancing,  etc. ;  in 
childish  play,  in  the  collection  of  worthless  things,  upon  which,  however, 
he  places  an  extraordinary  value,  etc.  For  this  form  of  mania  it  will  be 
most  convenient  to  keep  by  the  name  of  moria. 

The  foUowing  case  oflEers  an  example  of  this  kind  of  moderate,  uncomplicated, 
and  paroxysmal  exaltation,  not  progressing  to  fully  developed  mania  or  to  mono- 
mania.   

Example  XXXVI.— Johann  Reiberg,  set.  37,  vigorous,  without  hereditary 
tendency  to  insanity,  living  in  good  circumstances  as  an  agriculturist.  At  the 
age  of  twenty,  he  had  for  the  first  time  an  attack  of  insanity  which  lasted  for  six 
weeks  ;  since  that  time  he  had  seven  similar  attacks,  returning  at  intervals  of 
one,  two,  or  three  years. 

On  each  occasion  the  disease  followed  a  course  like  this  :— he  was  at  first,  for 
some  time,  dull  and  downcast  ;  then  there  succeeded  an  always  increasing  ex- 
citement, but  which,  even  in.  its  most  intense  paroxysms,  consisted  of  a  simple 
exaggeration  of  the  ordinary  dispositions  of  the  individual.  His  love  of  horses, 
dogs,  and  the  chase  became  stronger  than  ever,  and  he  displayed  extraordinary 
activity  in  agricultural  operations.  He  was  then  extremely  enterprising  ;  con- 
tinually busy,  and  engaged  from  morning  to  night,  without  rest,  in  the  hardest 
field-work.  He  had  a  great  opinion  of  himself,  and  easily  became  enraged.  His 
judgment  was  somewhat  feebler  on  these  occasions.  At  the  same  time,  he  was 
distant  in  manner ;  shunned  the  members  of  his  family,  and  in  their  presence 
was  cold  and  impolite.  During  these  fits  he  spent  the  night  generally  without 
sleep,  without  his  activity  suffering  in  the  least  from  that  cucumstance  on  the 
following  day.  The  appetite  increased  ;  and  although  when  not  suffering  from 
these  fits  he  was  temperate  as  respects  the  use  of  alcoholic  liquors,  he  had  then 
a  great  tendency  to  drink  without  going  the  length  of  intoxication.  Never, 
during  these  moments,  did  he,  to  say  the  truth,  suffer  from  any  profound  mtel- 
lectual  derangement ;  but  several  tunes  he  betrayed  passing  conceptions  bordering 
on  insanity.  In  all  the  fits,  insanity  did  not  betray  itself  except  by  a  general 
excitement  of  all  the  mental  faculties,  and  by  the  instinctive  character,  so  to 
speak,  of  those  acts  by  which  he  manifested  his  will  and  his  desires.  In  the 
course  of  from  four  to  five  weeks  this  state  attained  its  maximum,  and  the  ex- 
citement then  rapidlv  disappeared  ;  but  the  restoration  to  his  normal  character 
was  not  effected  until  after  the  intervention  of  a  period  of  dejection  similar  to 
that  which  marked  the  commencement  of  the  attack,  and  which  lasted  for  several 

days.  .  ,  ,  .     .   ,  J 

The  patient  himself,  while  the  attacks  lasted,  was  conscious  of  his  state,  and 
when  they  were  over  was  abashed  and  ashamed.  Several  times  he  showed  the 
desire,  if  the  attacks  were  renewed,  to  place  himself  under  medical  treatment  at 
Siegburg  At  length,  when  he  was  violently  seized  another  time,  he  was  con- 
ducted to  the  asylum,  in  September,  1829.  His  attack  had  by  that  time  nearly 
reached  its  height,  and  soon  began  to  decrease  and  to  give  place  to  the  ordinary 
period  of  dejection.     The  patient  then  returned  to  his  normal  condition. 

What  were  the  causes  which  from  time  to  time  induced  this  irritable  condition 
of  the  brain  and  entire  nervous  system,  which  sometimes  attained  an  extra- 
ordinary degree  of  intensity  ?  It  is  difficult  to  explain.  But  it  was  found  tliat 
the  patient  had  since  his  childhood  indulged  in  habits  of  onanism,  to  which  he 
yielded  himself  up  very  frequently.  Continually  tormented  by  remorse,  he  formed 
the  resolution  of  no  longer  abandoning  himself  to  his  unhappy  inclination  ;  but 
after  having  struggled  in  vain  for  some  time,  he  ended  by  yielding,  and  soon  after, 


212  STATES    OF    MENTAL    EXALTATION. 

following  the  exhaustion  of  the  brain  and  of  the  nervous  system,  there  came  the 
period  of  maniacal  excitement  which  we  have  described. 

The  treatment  consisted  in  a  moderate  diet  ;  tepid  baths,  with  cold  shower- 
baths  ;  moral  influence  and  compulsory  expedients  to  restrain  him  from  onanism. 
These  were  successful  in  keepmg  him  for  at  least  several  months  from  his  shame- 
ful habit.     (Jacobi,  '  Die  Hauptformen  der  Seelenstorungen,'  i.,  1844,  No.  1.) 

§  140.  Before  concluding  the  consideration  of  this  subject,  it  may  be 
well  to  say  a  few  words  regarding  the  so-called  mania  sine  delirio,  a 
pathological  variety  established  by  Pinel — we  may  say — to  the  detriment 
of  science;  for  so  true  and  so  serviceable  was  the  remark  which  Pinel  de- 
duced from  his  observations,  that  the  impulses  and  violent  actions  in 
mania  are  not  always  founded  upon  perversion  of  the  ideas — we  are  of 
opinion  nowadays  that  originally  this  is  altogether  not  the  case — so  con- 
fusing Avas  it  to  give  the  same  designation  to  two  different  morbid  mental 
states;  namely,  on  the  one  hand,  to  actual  periodic  attacks  of  fury  with  very 
little  delirium,  and,  on  the  other  hand  and  principally,  to  those  moderate 
states  of  mental  exaltation  referred  to  in  the  former  paragraph,  in  which 
the  patients  perform  foolish  actions  and  show  perversity  of  demeanor,  but 
are  also  in  a  position  to  justify  and  to  explain  their  conduct  by  a  course 
of  coherent  reasoning  which  still  lies  within  the  bounds  of  possibility,  i. 
e.,foUe  raisonnate.  The  disciples  of  Pinel  have  even  ranged  other  states 
under  the  same  title;  for  example,  that  condition  which  we  have  described 
as  a  moderate  degree  of  melancholia  with  violence,  and,  more  than  this, 
even  outbreaks  of  violence  in  consequence  of  hitherto  concealed  fixed 
ideas:  for  the  latter  there  is  not  even  the  appearance  of  reason. 

If  we  consider  more  closely  to  which  maniacal  states  the  designation 
mania  sine  delirio  can  be  applied,  we  recognize  the  fundamental  fact  that 
in  no  single  case  of  mania  is  the  conscious  thought,  the  intelligence,  per- 
fectly free  from  any  disorder.  Even  in  the  very  slightest  degrees  of 
mania  the  intelligence  participates  in  the  general  exaltation,  though  it  be 
only  to  the  extent  of  increased  livelmess  and  rapidity  of  thought;  gene- 
rally, however,  there  is  incoherence.  In  all  attacks  of  fury,  clear,  calm, 
healthy  thought  is  quite  impossible.  It  is  true  that  maniacs  can 
occasionally,  by  means  of  exhortation,  be  brought  for  a  short  time  to 
their  senses,  and  be  enabled  to  give  correct  answers;  but  this  only  shows 
as  Jessen'  remarked,  the  possibility  of  temporary  remissions  and  intermis- 
sions; "  the  patient  is  not  delirious  when  he  speaks  sensibly,  and  he  does 
not  speak  sensibly  in  those  moments  in  which  he  is  delirious."  Neither 
can  we  speak  of  the  absence  of  delirium  in  those  cases,  which  we  have 
described,  where  there  is  a  morbid  impulse  to  commit  acts  of  violence. 
Then  those  murderous  ideas  which  are  not  at  all  in  accordance  with  ex- 
ternal moral  causes,  but  awakened  by  a  morbid  disposition,  are  already  in 
themselves  delirious  ideas,  just  as  in  furious  mania,  and  in  all  violent 
emotion — for  example,  rage — there  arise  new  ideas,  opinions,  and  conclu- 
sions, corresponding  to  the  morbid  disposition. 

Those  states  in  which  there  is  least  confusion  of  ideas  and  delirious 
perceptions,  in  which  there  is  the  greatest  amount  of  logical  coherence  in 
thought,  are  the  slight  states  of  exaltation  which  we  have  described  in 
the  foregoing  paragraph,  which,  however,  are  generally  merely  the  fore- 
runners of  the  commencement  of  violent  mania.  For  these,  for  folie 
raisonnante,  we  might,  as  Pinel  in  part  did,  use  the  name  mania  sine 
delirio;  but,  as  in  concrete  cases  it  is  of  little  practical  advantage  to  range 
cases  under  consideration  under  certain  names,  but  of  far  more  to  obtain 

'  '  Berl.  Encycl.  Worterbuch,'  xxii  ,  p.  420. 


STATES    OF    MENTAL    EXALTATION.  213 

a  jjsychological  appreciation  of  the  fundamental  morbid  psychical  state, 
the  circumstances  which  have  caused  its  development  and  its  consequences, 
it  is,  at  all  events,  more  advisable  to  allow  those  obscure  names  which 
provoke  the  curiosity  of  lawyers  and  other  laymen  to  fall  completely  into 
disuse. 

In  a  court  of  law  the  morbid  nature  of  these  states  is  most  easily  demonstrated 
in  cases  where  the  disorder  has  come  on  tvithin  a  short  time,  or  returns  at  inter- 
vals, and  therefore  admits  of  comparison  with  the  state  of  health  in  the  same 
individual;  also  in  cases  where  there  are  concomitant  nervous  or  other  bodily 
symptoms.  It  is,  on  the  contrary,  difficult  to  prove  that  a  certain  state  is  morbid 
when  it  has  been  slow  and  gradual  in  its  development,  when  it  has  become  habit- 
ual and  passed  into  fixed  peculiarity  of  character.  It  should  constantly  be  borne 
in  mind  that  an  individual  may  talk  "quite  rationally,"  and  at  the  same  time 
show  by  his  acts  and  by  his  conduct  (and  even  by  what  he  does  not  do)  that  he  is 
mentally  deranged. 

Section  II. — Monomania. 

§  141.  Under  the  term  monomania  are  comprehended  those  states  of 
exaltation  which  are  characterized  by  affirmative  expansive  emotions,  ac- 
companied by  persistent  over-estimation  of  self,  and  the  extravagant 
fixed  delirious  conceptions  which  proceed  therefrom. 

It  is  this  form  which  Heinroth  has  described  in  great  part  under  the  name  of 
Ecstasis  paronoica,  and  which  Jessen  has  designated  Schivdrmerei  (and  in  part 
Aherwitz,  craziness).  Our  form  only  corresponds  in  part  with  those  states  de- 
scribed by  Jacobi  as  monomania,  as  the  latter  also  included  melancholia  with 
delirious  conceptions.'  The  majority  of  the  French  medical  psychologists  call 
these  states  monomania  (acute)  of  ambition,  of  pride,  of  vanity;  also  (according 
to  Rush)  amenomania.  These  conditions  are,  it  is  true,  specially  observed  in 
many  of  the  cases  which  terminate  in  dementia  and  paralysis;  but  it  would  be  very 
erroneous  to  suppose  that  monomania  is  always  the  first  stage  of  this  form — it 
frequently  terminates  in  recovery  without  any  paralytic  appearances,  and  the 
"  monomaniacal "  delirium  of  paralytics  has  moreover  something  peculiar,  namely, 
the  early  invasion  of  symptoms  of  mental  weakness. 

We  refer  the  reader,  in  the  first  place,  to  what  has  been  said  concerning  the 
states  of  exaltation  in  general,  and  also  to  paragraph  135,  and  may  now  proceed 
to  a  short  description  and  explanation  of  the  morbid  phenomena  in  monomania. 

Anomalies  of  Self -consciousness,  the  Desires  and  the  Will. — In  this 
form  of  insanity  these  are  all  grouped  together  round  a  common  centre,  viz. 
the  exaggerated  idea  which  the  patient  has  of  himself.  This  is  psychic- 
ally grounded.  Inasmuch  as  the  power  of  volition,  which  during  the 
melancholic  stage  was  weakened  or  entirely  suppressed,  has  not  only  re- 
turned, but  is  actually  exalted  (externally  in  the  form  of  increased 
activity) — inasmuch  as,  at  the  same  time,  this  freedom  of  impulse  to 
action  is  accompanied  by  great  freedom  of  thought  and  an  abundant 
flow  of  ideas — there  results  a  feeling  of  great  self-satisfaction;  the  patient 
rejoices  over  his  gi-eat  mental  (and  bodily)  well-being;  he  feels  himself 
richer  and  more  free;  every  exertion  has  become  easy  to  him;  therefore 
he  considers  himself  to  be  not  only  perfectly  healthy — and  rejects  with  in- 
dignation any  expression  to  the  contrary — but  he  frequently  declares  that 
he  never  in  his  life  felt  so  well  and  so  happy.  The  exalted  self-conscious- 
ness manifests  itself  as  an  elevated  frame  of  mind,  as  a  joyful  disposition, 
sometimes  with  the  visionary  enjoyment  of  sublime  sensations;  it  is 
further  manifested  in  great  self-confidence,  in  presumptuous,  audacious, 
proud,  and  supercilious  behavior,  in  which  the  patient  displays  sometimes 

'  In  several  parts  of  his  work  upon  Mania,  for  example,  in  the  18th  and  19th 
illustrative  cases. 


21i  STATES   OF    MENTAL.   EXALTATION. 

a  superficial  self-satisfied  aflfected  bearing,  sometimes  a  more  deeply  seated 
haughtiness  and  pride,  and  a  desire  to  magnify  himself  in  every  possible 
way.  This  afiirmative  disposition  is  persistent,  it  does  not  alternate  with 
other  dispositions  without  external  motive,  as  is  the  case  in  mania.  It 
may,  of  course,  be  momentarily  interrupted  by  external  circumstances. 
The  patient  becomes  irritable  and  violent;  and  if  any  one  expresses  a  doubt 
as  to  the  accuracy  of  his  assertions,  or  opposes  by  remonstrance  or  force 
the  execution  of  his  extravagant  acts,  he  at  once  becomes  impatient  and 
angi-y ;  he  seeks  to  justify  his  actions  and  ideas,  and  will  permit  nothing  to 
approach  him  which  might  encroach  upon  his  elevated  frame  of  mind. 

The  increased  power  of  volition  is  manifested  in  the  necessity  for  in- 
creased eccentric  activity,  especially,  however,  in  numerous  extravagant 
plans  and  projects,  the  accomplishment  of  which  appears  quite  possible 
and  easy  to  the  patient,  who  believes  himself  capable  of  anything.  In 
this  he  presents  a  great  similarity  to — yet  with  a  marked  diflierence  from 
— the  demeanor  of  the  maniac.  For,  as  in  mania,  so  in  monomania,  the 
primary  and  principal  desire  is  that  of  manifestation  of  power;  but  in 
mania  this  necessity  of  an  emotional  explosion  immediately  produces 
muscular  movements  (sometimes  tumultuous)  in  which  it  relieves  itself. 
Hence  the  instinctive  character,  but  outwardly  exalted,  of  these  states. 
The  more,  on  the  contrary,  that  co-ordinated  series  of  morbid  ideas  and 
opinions  act  upon  the  exalted  will,  the  more  the  current  towards  the  ex- 
terior is  set  in  motion,  not  merely  by  an  obscure  tumultuous  necessity, 
but  by  conscious  thoughts — the  more,  therefore,  that  some  sort  of  plan 
presides  over  the  morbid  will,  the  further  is  the  condition  removed  from 
mania  and  drawn  towards  monomania. 

This  difference  is  seen  most  distinctly  when,  as  is  very  often  observed,  certain 
groups  of  sensations  and  obscure  ideas  appear  with  especial  vivacity  and  urge 
themselves  towards  the  exterior  as  instincts;  for  example,  the  sexual  passion. 
The  maniac  vs^itli  simple  exaltation  of  the  sexual  instinct  seeks  to  gratify  his 
desire  in  the  most  direct  manner;  he  attacks  every  female  who  comes  in  his  way; 
and  the  nymphomaniac  makes  obscene  advances  to  every  visitor.  In  monomania, 
on  the  contrary,  the  exalted  sexual  instinct,  before  it  passes  into  action,  is  guided 
by  new  ideas  and  opinions  (of  a  morbidly  exalted  kind)  which  occupy  the  mind: 
the  patient  will  then  only  gratify  his  desires  in  the  sense  of  his  over-estimate  of 
self  and  of  certain  delirious  ideas;  he  only  pays  his  addresses'  to  princesses  and 
illustrious  ladies;  the  female  patients  have  imaginary  love  adventures  with  princes 
and  kings,  etc.  i .      , 

Thus  the  excitement  of  the  monomaniac  does  not  pass  so  immediately  towards 
the  exterior;  effort  is  accompanied  by  clear  conscious  thoughts  and  opinions,  loses 
thereby  the  instinctive  character,  and  becomes  actual  morbid  volition.  With  far 
greater,  sometimes  with  perfect  outward  calm,  there  is  a  more  profound  internal 
loss  of  reason  than  in  mania,  because  consequences  soon  result  from  the  general 
exaltation  which  set  aside  the  essential  conditions  of  healthy  mental  action. 

Anomalies  of  the  Intelligence.— B.eve,  also,  there  is  first  of  all  obser- 
vable a  purely  formal  increase  in  the  vivacity  and  rapidity  of  thought, 
which  is  manifested  in  exuberance  of  ideas — owing  to  which  the  patient 
inwardly  rejoices — in  lively  conversation,  and  in  frequent  change  of  the 
object  towards  which  the  morbid  volition  is  directed.  But,  ordinarily, 
this  occurs  only  at  the  commencement;  afterwards  a  few  delirious  ideas 
exclusively  predominate,  and,  without  interchange  with  others,  deter- 
mine the  actions. 

Another  anomaly  of  the  intelligence  consists  in  an  inward  increase, 
an  exaggeration,  of  the  ideas  in  regard  to  their  subject,  which  shows  it- 

1  See  further  on  a  case  of  this  kind. 


STATES    OF    MENTAL    EXALTATION.  21S 

self  by  a  tendency  always  to  employ  grand,  high-sounding  words,  the  most 
brilliant  images,  the  highest  possible  numbers  (thousands,  millions,  etc.); 
and  inasmuch  as  those  overdrawn  ideas  pass  into  acts,  they  explain  the 
numerous  eccentric  plans  of  such  patients.  These  naturally  vary  very 
much,  according  to  the  former  circumstances  of  life,  employment,  and 
degree  of  education  of  the  patient.  The  artisan  magnifies  his  employ- 
ment to  the  utmost;  the  soldier  dreams  of  large  armies,  enters  upon  cam- 
paigns and  makes  conquests:  another  seeks  to  solve  impossible  mechan- 
ical problems,  such  as  perpetual  motion;  others  discover  new  means  of 
locomotion  by  land  and  sea,  new  railways,  or  steamboat  enterprises  to  com- 
mand all  the  seas  of  the  world;  or,  again,  he  projects  impracticable  jour- 
neys, or  immense  architectual  plans  (castles,  towns,  etc.)  entirely  occupy 
his  mind.  Others  busy  themselves  within  the  sphere  of  ideas;  conceive 
comprehensive  scientific  thoughts,  great  humane  and  rehgious  aims,  etc. ; 
believe  themselves  to  be  apostles,  benefactors  of  the  whole  family  of  man- 
kind, bearers  of  universal  happiness  and  peace,  etc.;  all  in  accordance 
with  the  accidental  external  influences  or  the  former  practical  tendencies 
or  speculative  aims  of  the  patient.  These  ideas,  however,  are  invariably 
distinguished,  in  the  first  place,  by  the  feature  of  activity  (in  opposition 
to  the  ideas  in  melancholia,  where  the  patient  believes  he  is  governed  and 
tormented  by  external  influences),  and,  in  the  second  place,  by  their 
fantastic  exaggeration. 

Most  intimately  connected  with  these  ideas,  and,  like  them,  proceeding 
from  increased  self-consciousness  and  over-estimation  of  the  individual 
powers,  there  arise,  further,  false  ideas  and  opinions  relating  to  the  spe- 
'^  ci.al  ego  and  its  connection  with  the  external  world.  In  these  cases  we  fre- 
quently meet  with  the  idea  of  being  some  distinguished  person:  a  super- 
human power  of  possessing  inexhaustible  resources,  of  occupying  a  high 
position,  of  aristocratic  descent,  etc.  To  this  class  belong  those  patients, 
so  numerous  in  asylums,  who  believe  that  they  are  generals.  Napoleons, 
millionnaires,  reformers  of  the  world,  gods  and  heroes;  the  many  female 
patients  who  are  beloved  by  kings,  those  who  believe  that  they  hold  fre- 
quent and  intimate  converse  with  the  Deity,  etc.  But  all  such  belong  to 
this  class  only  in  so  far  as,  and  so  long  as,  these  ideas  depend  upon  an 
actually  existing  increased  consciousness  of  self,  to  which  they  again 
stand  in  the  relation  of  attempts  at  explanation. 

These  false  ideas  have  originally  a  significance  such  as  the  following:  the  idea 
of  being  Napoleon,  for  example,  fundamentally  means  that  the  patient  feels  him- 
self powerful,  believes  himself  capable  of  doing  great  things,  of  accomplishing  all 
things  by  his  great  mental  and  physical  powers  to  a  degree  of  which  he  had  never 
before  even  dreamed,  and  could  only  be  possible  to  one  of  the  few  great  men  of 
history. 

Afterwards  this  affirmative  disposition  often  becomes  weaker,  and  even  com- 
pletely disappears,  when  the  delirium  alone  remains.  The  more  the  elevated 
frame  of  mind,  which  was  originally  attempted  to  be  explained  by  the  delirium, 
disappears,  the  more  does  the  still  existing  delirium  degenerate  into  mere  words, 
to  which  the  patient  no  longer  attaches  any  real  significance,  and  the  more  does 
he  pass  into  another  condition,  that  of  dementia  with  the  character  of  exalta- 
tion. 

So  long,  however,  at  this  exalted  frame  of  mind  continues  to  provoke  attempts 
at  explanation,  we  can  with  instruction  observe  the  progress  of  this  exaggeration 
in  the  delirious  ideas.  A  patient,  for  example,  who  had  formerly  been  a  common 
soldier,  manifests  at  first  merely  the  idea  of  being  an  officer;  in  a  few  days  he  is  a 
general,  and  soon  the  leading  warrior  of  the  day:  and  should  this  not  suffice— 
should  these  words  not  be  strong  enough  to  express  the  power,  the  freedom,  and 
the  delight  which  he  feels  within  him,  he  becomes  Lord  of  the  universe,  the 
Messiah,  the  Saviour,  God;  in  short,  he  uses  the  highest  and  strongest  expressions 
of  which  he  is  aware  to  denote  his  imaginary  greatness. 


216  STATES    OF    MENTAL    EXALTATION. 

It  would,  however,  be  a  very  great  error  to  suppose  that  the  patient  is  con- 
scious of  this  explanation,  as  such — that  he  calnily  considers  what  may  be  the 
cause  of  his  frame  of  mind.  This  is  not  the  case:  the  ideas  called  forth  by  the 
frame  of  mind  arise  suddenly,  as  in  a  dream,  and  while  he,  at  first  perhaps  over- 
joyed, shocked,  timid,  or  frightened  by  them,  may  be  able  to  suppress  them,  yet 
they  soon  intrude  themselves  upon  him  so  fixedly  and  so  perseveringly,  that  he 
can  no  longer  doubt  their  reality;  for  them  he  renounces  all  his  former  views  and 
ideas,  surrenders  his  old  ego,  and  will  even  deny  the  testimony  of  his  senses. 

Not  unfrequently,  when  these  states  have  attained  to  a  considerable  develop- 
ment, weakness  of  the  mental  processes  ensues  (consisting  at  first  generally  in. 
loss  of  memory  and  confusion  of  ideas).  The  patient,  however,  does  not  cease  to 
imagine  things,  particularly  in  regard  to  his  exalted  feeling  of  satisfaction:  but  it 
appears,  often,  as  if  he  were  affecting  arrogance  and  gi-eatness  merely  with  the 
xiew  of  deceiving  himself  and  others,  with  reference  to  the  already  perceptible 
urgent  and  increasing  weakness  of  dementia — of  concealing,  by  a  kind  of  morbid 
pride,  a  commencing  void  and  emptiness — but  of  course  with  no  direct  intention. 
While,  then,  gradually  this  disorder  of  the  intelligence  becomes  a  confused  mass 
of  grand  words  and  figures,  it  soon  occurs,  wliere  the  mental  processes  remain 
active,  that  certain  of  these  delirious  conceptions  become  completely  fixed. 
Certain  steadfast,  connected  circles  of  ideas  then  incessantly  urge  themselves  into 
the  foreground  of  the  consciousness,  govern  all  the  thoughts,  and  are  expressed 
in  words  and  deeds.  From  this  cause  it  may  seem  as  if  there  were  merely  a  par- 
tial destruction  of  the  intelligence,  while  in  reality  the  essential  elements  of 
thought — normal  self -consciousness,  and  a  correct  appreciation  of  the  special  in- 
dividuaUty  and  its  relation  to  the  world — are  utterly  perverted  and  destroyed. 

Of  these  fixed  ideas,  w^hich  to  him  possesss  the  highest  degree  of  subjective 
reality,  the  patient  cannot  be  divested  either  by  demonstration  or  by  evidence. 
It  is  only  at  the  commencement  that  remissions  occasionally  occur,  dxiring  which 
the  patient  may  admit  for  a  short  time  the  error  of  his  delusion,  when  reasons  or 
external  evidence  are  laid  before  him;  while  at  the  same  time  he  cannot  inwardly 
convince  himseK  of  the  falsity  of  his  ideas. 

§  142.  Anomalies  of  the  Sensorial  Functions,  the  Movements  and  the 
Conduct. — Hallucinations  and  illusions  corresponding  to  the  dominant 
disposition  are  frequently  present,  and  are  much  more  serious  in  their 
consequences  than  they  are  in  mania.  In  the  latter  they  are  soon  for- 
gotten; but  here  they  persist,  foster,  and  essentially  strengthen  the  deli- 
rious conceptions.  The  patient,  for  example,  sees  an  angel  bringing  to 
him  a  message  from  heaven;  hears  voices  commanding  him  to  commit 
certain  deeds,  or  communicating  unintelligible  nonsense,  which  he  believes 
to  be  some  divine  mystery;  worthless  objects  appear  precious,  etc. 

The  movements  of  the  monomaniac  do  not,  on  the  whole,  present  the 
external  excitement  and  tumultuous  violence  Avhich  appear  in  simple 
mania;  they  are  generally  more  calm,  and  any  excitement  is  usually  the 
result  of  some  external  motive.  An  uncertainty  in  the  muscular  move- 
ments is  here  also  very  frequently  the  first  premonitory  symptom  of  a 
fatal  termination — of  the  commencement  of  general  paralysis. 

The  outward  appearance  and  conduct  of  these  patients  is  in  accordance 
with  those  anomalies  which  we  have  described.  One  displays  the  gestures 
of  pride  and  of  power;  another  appears  as  a  theatrical  hero,  full  of  high- 
sounding  words;  while  others  are  very  polite,  affected,  gracious  and 
affable  in  their  demeanor.  Some  dress  fantastically;  others,  especially 
females,  with  extraordinary  elegance;  others,  again,  are  totally  neglectful 
of  their  toilette,  forgetting  everything  in  the  contemplation  of  extravagant 
plans.  These  patients  delight  in  giving  orders,  and  are  impatient  to 
know  that  their  commands  are  promptly  executed;  they  are  covetous, 
generous,  and  profligate.  According  to  the  nature  of  the  dominant 
delirious  ideas,  they  make  various  arrangements  for  the  carrying  out  of 
their  desires:  letters,  requisitions,  and  proclamations  are  issued;  large 
purchases   are  made,  and  polite  announcements  prepared;  they  bestow 


STATES    OF    ilENTAL   EXALTATION.  21 7 

orders  and  titles  ■with  a  liberal  hand,  they  prepare  laborious  statistics  and 
complicated  plans  for  the  reorganization  of  the  world,  etc.  Some  patients 
appear  perfectly  calm:  their  conversation  and  conduct  indicates  an  exalted 
tranquil  joy,  a  sort  of  inward  rapturous  revelry  of  feeling.  With  this 
there  are  generally  associated  ideas  of  close  and  mystical  connection  with 
the  Deity,  Messianic  ideas,  etc.,  combined  with 'hallucinations — which 
they  carefully  conceal — of  the  appearance  of  angels,  heavenly  voices,  etc. 
This  is  the  weak  sentimental  form  of  monomania,  which  is  observed  princi- 
pally in  onanists;  but  this  visionary  happiness  may  also  be  interrupted  by 
violent  outbreaks  of  anger  when  their  wishes  are  opposed,  accompanied  by 
threats  of  Divine  displeasure,  and  solemn  prophecies  of  dreadful  pimish- 
ments  which  are  certain  to  follow.  In  women  similar  states  of  inward 
rapture  occur,  having  for  their  object  sexual  sensations  and  imac^inary 
love  affairs:  they  also  are  accompanied  by  numerous  but  well-concealed 
hallucinations. 

According  to  the  predominance  of  certain  fixed  ideas,  or  efforts  dependent, 
upon  delirious  conceptions,  special  forms  of  monomania  have  been  distinguished 
and  called  by  such  names  a^  Theomania.  Erotomania,  etc. 

Tlie  other  symptoms,  although  here  also  the  cerebral  disease  may  be  accom- 
panied by  the  most  numerous  and  varied  disorders  of  the  general  health,  present 
nothing  peculiar,  and  are  veiy  similar  to  those  observed  in  miinia.  At  the  com- 
mencement, when  the  attack  is  acute,  a  feverish  condition  frequentlv  exists; 
afterwards,  sleeplessness,  constipation,  and  sometimes  cerebral  congestion. 

§  143.  The  form  of  monomania  is  dcTeloped,  like  mania,  generally  after 
a  stage  of  melancholy  has  passed  off.  At  first  the  state  of  exaltation  may 
rest  for  a  long  time  indeterminate  between  the  two  forms.  When  cer- 
tain delirious  conceptions  become  fixed,  the  patient  enters  into  an  essen- 
tially different  state:  and  this  condition,  that  of  confirmed  mouomania. 
is,  for  the  reasons  already  stated,  to  be  considered  a  much  more  serious 
affection  than  mania.  The  more  calm  the  external  behavior  of  the 
patient  gradually  becomes — the  more  the  alternation  of  the  false  ideas 
recedes,  and  only  a  few  particular  but  fixed  ideas  remain — the  more 
there  existed  in  the  former  individuality  of  the  patient  certain  peculiari- 
ties which  favor  the  rapid  penetration  and  falsifying  of  the  ego  bv  these 
fixed  ideas,  the  less  is  a  return  to  health  to  be  looked  for. 

During  the  course  of  these  states  there  recur  remissions  which  are 
more  apparent  than  real:  they  have  more  the  nature  of  an  external 
quieting  than  of  an  internal  cessation,  and  are  only  a  calmer  occupa- 
tion of  the  mind  by  the  delirium:  complete  intermissions  only  take 
place  when  the  disease  is  still  vacillating  between  mania  and  mouomania. 

The  patient  may  recover.  Then  it  seems  to  him  as  if  a  veil  liad 
suddenly  fiillen  from  his  eyes:  he  awakes  as  if  from  a  dream,  and  cannot 
understand  why  simple  reasoning  in  relation  to  his  delusion,  which  is 
now  quite  clear  to  him,  could  make  no  impression  upon  him  during  the 
disease.  He  is  now  accessible  to  reason;  still  it  is  often  necessary  to  aid 
his  comprehension  by  explanations  and  palpable  evidence  in  order  to 
completely  counteract  the  delirious  ideas  which  still  occasionally  arise, 
although,  upon  tlio  whole,  they  are  recognized  by  him  as  false.  "A  com- 
pletely fixed  exalted  delusion,  Avheii  it  has  continued  for  more  than  half 
a  year,  is  not  easily  got  rid  of;  nevertheless,  cases  sometimes  occur 
where  the  monomania  gradually  disappears  after  it  has  lasted  for  several 
years:  when  this  occurs,  other  morbid  jnvcesses  are  generally  developed. 
All  symptoms  of  commencing  mental  weakness — loss  of  memory,  recur- 
rence of  incoherence,  etc.,  indicate  that  the  patient  is  becoming  incurable. 


218  STATES    OF    MENTAL    EXALTATION". 

When  he  does  not  recover,  he  never  continues  during  the  whole  of 
his  future  life  in  the  state  of  high  emotional  exaltation  which  is  proper 
to  this  form  of  insanity.  The  affirmative  disposition,  the  elevated  frame 
of  mind  disappear,  and  its  products,  the  fixed  delirious  conceptions, 
alone  remain;  external  calm  returns,  and  the  general  health  improves;  or 
the  patient,  owing  to  the  development  of  serious  anatomical  lesions 
within  the  cranium,  gradually  falls  into  a  state  of  profound  dementia. 

§  144.  It  is  very  interesting  to  observe  the  close  analogy  that  exists 
in  essentials  between  the  symptoms  and  modes  of  termination  of  the 
maniacal  forms  and  those  of  alcoholic  intoxication.  This  analogy  is 
sometimes  observed  even  in  the  premonitory  symptoms.  There  are 
drunkards  on  whom  wine  has,  first  of  all,  the  effect  of  rendering  them 
quiet,  thoughtful,  and  self-concentrated,  presenting  an  analogy  to  the 
preliminary  melancholic  period. 

The  essential  action,  however,  of  alcoholic  drinks  is  excitation,  expan- 
sion of  all  the  mental  processess,  volition  especially  becoming  easier  and 
more  free.  At  first  the  ideas  succeed  each  other  more  rapidly,  the  imag- 
ination becomes  more  brilliant,  the  language  abounds  in  striking  and 
surprising  inflections,  thoughts  arise  as  if  spontaneously,  conversation 
proceeds  more  easily,  and  muscular  action  is  more  energetic:  to  this  cor- 
responds usually  the  joyful  frame  of  mind,  the  psychical  pleasure  and 
power.  Afterwards  the  drunken  man  throws  off  all  restraint;  the  objects 
of  the  precipitate  and  rapidly  succeeding  preceptions  are  immediately, 
a,nd  without  reflection,  thrown  outwards  in  words  and  actions;  thoughts 
formerly  kept  concealed  escape  from  him  involuntarily,  or  he  takes 
pleasure  in  giving  expression  to  ideas  of  his  own  self-importance;  he 
manifests  fearlessness,  courage,  a.  degree  of  self-confidence  frequently 
approaching  to  insolence;  he  is  a  braggard;  he  is  generous  and  prodigal, 
because  he  appears  to  himself  to  be  richer  than  he  really  is.  Frequently 
certain  desires  and  tendencies  appear  with  especial  force  and  reckless- 
ness; for  example,  the  desire  to  speak  in  verse,  to  converse  in  a  foreign 
language  (especially  in  Latin),  to  sing,  to  scream,  to  quarrel,  etc.  He  is 
Tery  irritable,  and,  like  the  monomaniac,  nothing  offends  him  more 
than  to  be  told  that  he  is  drunk.  The  humor  may  change  with  or  with- 
out external  motive;  occasionally  sad  ideas  involuntarily  arise  in  his 
mind,  and  he  begins  to  weep  bitterly;  sometimes  he  becomes  tender  and 
sentimental;  sometimes  the  impulse  to  increased  evolution  of  force 
urges  him  to  senseless  dangerous  acts,  to  strike  all  around  him,  and  he 
becomes  slightly  delirious.  While  in  this  state,  a  strong  mental  impres- 
sion has  sometimes  such  an  effect  upon  him  that  he  immediately  becomes 
sensible,  and  the  intoxication  is  suddenly  cut  short. 

Afterwards  still  greater  incoherence  ensues.  The  drunkard  has  his 
hallucinations  and  illusions;  he  mechanically  repeats  what  he  has  already 
said,  his  memory  fails,  and  he  becomes  quite  incapable  of  calling  forth 
new  series  of  ideas;  in  short,  he  falls  into  a  state  of  dementia.  Now 
presenting  a  striking  analogy  to  the  commencement  of  general  paralysis,  the 
speech  falters,  the  movements  of  the  tongue  are  irregular,  the  voluntary 
muscles  lose  their  energy,  the  legs  are  no  longer  able  to  carry  the  body, 
and  the  individual  falls  into  a  state  of  powerlessness  resembling  the  ady- 
namic condition  of  the  nervous  system  in  typhus  fever,  or  general  par- 
alysis with  dementia. 

The  phenomena  in  insanity  pursue,  on  the  whole,  the  same  course, 
but  proceed  more  slowly.  From  a  preliminary  state  of  exaltation  of  the 
sensations  and  emotions,  of  the  intelligence  and  of  the  will,  the  insane 


STATES    OF    MENTAL    EXALTATION".  219 

man  gradually,  as  tlie  cerebral  disease  progresses,  falls  into  a  condition 
of  mental  weakness,  with  loss  of  command  over  the  faculty  of  speech  and 
all  voluntary  movements. 

EXA.MPLE  XXXVII. — Cerebral  congestion;  melancholy;  tnononiania  terminating 
in  dementia. — O— ,  an  officer,  enjoying  habitual  good  health,  and  a  strong  consti- 
tution, had  in  his  youth  indulged  in  a  multitude  of  excesses,  which  had  not  been 
followed  by  any  appreciable  bad  consequence.  He  was  irritable,  violent,  flighty, 
and  so  unstable  in  his  talk,  that  often,  in  telling  a  story,  he  would  pass  from  one 
to  another  without  finishing  any.  For  a  long  time  he  lived  carelessly  in  that 
fashion;  and  then  dark,  hypochondriacal  ideas  gradually  took  possession  of  him. 
He  suffered  from  constipation  and  internal  haemorrhoids.  He  was  always  dejected, 
and  nothing  could  distract  him.  In  a  fall  which  he  had  from  his  horse,  he 
received  a  severe  contusion  on  the  head  and  on  the  leg,  and  was  obliged  for  three 
months  to  maintain  a  horizontal  position.  The  congestion  of  the  head,  combined 
with  the  haemorrhoidal  affection,  now  increased  to  such  a  degree,  that  he  experi- 
enced frequent  attacks  of  vertigo  and  confusion,  and  could  only  with  great  diffi- 
culty perform  the  duties  of  his  office,  His  pulse  was  full  and  slow;  his  belly  dis- 
tended; his  countenance  flushed.  He  had  violent  headaches  and  lumbar  pains; 
had  a  constant  feeling  of  tiredness;  micturition  was  painful,  and  the  bowels  con- 
stipated. At  the  same  time,  he  was  in  a  constant  state  of  mental  anxiety.  He 
often  clasped  his  hands,  as  if  he  were  the  victim  of  the  most  profound  despair. 
He  refused  at  times  to  eat  or  drink,  and  constantly  dreaded  that  for  his  neglect  of 
military  duty  and  for  his  crimes  (purely  imaginary)  he  would  be  degraded  and 
prosecuted  criminally,  etc.  At  the  end  of  two  months  he  felt  improved,  and  in 
two  months  more  was  completely  restored. 

But  when  his  physician  saw  him  again  in  the  commencement  of  November,  he 
found  him  in  an  agitated  condition,  occupying  a  well-furnished  apartment.  He 
observed  in  him  at  the  same  time  an  extraordinary  flow  of  language,  and  great 
ao-itation  of  the  whole  body.  Already  on  the  following  morning  the  monomaniac 
exaltation  had  reached  a  Very  considerable  height.  He  got  ready  to  visit  the 
daughter  of  a  superior  officer,  whom  he  was  but  slightly  acquainted  with,  and 
whose  hand  he  was  about  to  ask.  He  had  ah-eady  bought  a  carriage  and  horse  for 
the  purpose  of  making  a  long  journey  with  this  lady  through  Europe.  He  declared 
himself  to  be  of  noble  blood,  and  announced  that  his  promotion  was  to  be  very 
rapid.  His  happmess  was  at  the  highest  pitch,  and  he  wished  to  share  it  with  the 
whole  world.     Checked  in  his  desires,  he  fell  into  a  fit  of  frenzy. 

Towards  the  end  of  November  he  entered  Siegburg.  The  pupds  were  somewhat 
contracted;  the  haemorrhoidal  vessels  were  swollen;  he  had  pains  in  the  joints; 
there  was  a  determination  of  blood  to  the  head;  the  pulse  was  rapid.  He  was  very 
Irritable,  and  easily  became  enraged.  He  imagined  that  he  possessed  a  consider- 
able fortune,  and  was  of  lofty  station;  he  believed  himself  endowed  with  super- 
natural power,  etc.  Every  minute  he  distributes  the  largest  sums  of  money,  one 
hundred  and  twenty  millions  of  louis-d'or;  afterwards  he  says  that  he  is  God  the 
Father;  but  if  any  one  asked  who  his  father  was,  he  replied  that  he  was  a  judge 
in  the  court  of  exchequer;  and  it  was  in  vain  that  one  tried  to  show  him  that  what 
he  said  was  absurd  and  impossible.  At  another  time  he  said  that  he  had  been  in 
heaven,  and  that  he  saw  an  exceedingly  beautiful  Venus;  the  following  day  he  said 
that  he  found  himself  in  the  midst  of  several  hundreds  of  Venuses.  He  wished  to 
increase  aU  the  rooms  of  the  asylum  by  means  of  gas,  and  to  give  them  consider- 
able proportions.  He  wished  to  increase  men  in  size,  and  to  make  them  giants. 
He  wished  to  raise  the  dead;  and  especially  he  wished  to  transport  thousands  of 
reo-iments  in  the  air  by  millions  of  balloons,  etc.  Ten  months  after  his  admission, 
the  attacks  of  vertigo  retmned,  and  by  degrees  symptoms  of  general  paralysis 
with  increasing  dementia  developed  themselves;  apoplectiform  attacks;  death. 
(Jacobi.  'Beobachtungen,'etc.,  i.,  1830,  p.  372.) 

Example  XXXVIII. — Monomania  terminating  in  dementia.— 3.  U — ,  aet,  44, 
formerly  an  officer,  manifested  ali-eady  for  a  lengthened  period  a  certain  hasti- 
ness in  his  acts  and  movements.  He  was  restless  and  imtable.  In  the  winter  of 
1824,  even  when  he  still  punctually  attended  to  his  business,  he  began  to  seclude 
himself  more  in  his  chamber,  which  he  had  adorned  in  a  somewhat  fantastic 
manner,  and  read  a  book  of  very  fine  type  by  the  light  of  a  large  lamp,  and  with 
a  powerful  jnagnifying  glass.  In  spring,  symptoms  of  emotional  excitement 
were  already  manifest.  In  July,  there  appeared  ideas  of  the  possession  of  an 
immense  fortune  and  of  an  elevated  position.  Soon  he  believed  himself  to  be  the 
Prince  of  Neuchatel;  and  at  the  same  time  he  thought  himself  a  great  painter, 


220  STATES    OF    MENTAL    EXALTATION. 

and  spent  the  entire  day  in  designing  and  coloring  landscapes,  as  children  of  five 
or  six  years  do,  and  showed  them  to  everybody  as  chefs-d'oeuvre. 

In  a  few  days  he  was  admitted  into  Siegburg.  The  pupils  were  contracted. 
He  had,  at  tlie  root  of  the  nose,  a  deep  scar,  the  result  of  a  wound  which  he  had 
received  at  the  age  of  twenty-five  by  falling  from  a  carriage.  His  speech  was 
hesitating  and  fast.  He  had  several  stools  per  day.  The  pulse  was  soft  between 
95  and  100.  Trembling  in  the  limbs;  in  the  evening  a  kind  of  epileptic  attack, 
followed  by  great  excitement;  palpitation  of  the  heart;  oppression;  the  subcu- 
taneous veins  were  greatly  swollen  (bloodletting). 

The  following  morning  he  was  calm,  very  happy,  walking  continually  from 
one  side  to  the  other.  Later,  great  agitation.  The  patient  washed  his  head  with 
his  urine,  saying,  by  way  of  excuse,  that  it  was  the  fashion  of  the  Hottentots, 
Often  he  requested  some  one  to  get  ready  his  carriage  and  saddle  his  horse,  and 
beat  his  keeper  because  he  refused  to  obey  him.  Sometimes  he  cried  and  shouted 
when  hindered  from  indulging  in  his  insane  practices.  The  countenance  was 
pale;  the  look  fixed;  the  head  hot  and  flushed.  He  slept  a  little  at  night  (baths, 
tartar  emetic,  bleeding,  seclusion,  moderate  diet,  tincture  of  digitalis;  later, 
leeches  and  calomel).  Sometimes  the  patient  rubbed  his  head  with  his  excre- 
ment. He  collected  pebbles,  to  which  he  attached  great  value,  saying  that  they 
were  diamonds.  He  said  that  he  was  going  to  Mexico  with  a  great  retinue, 
because  he  Avas  appointed  ambassador,  etc. 

Gradually  he  became  more  calm,  the  pulse  slower,  the  temperature  of  the  body 
normal.  An  abscess  found  on  the  hip,  which  soon  healed.  He  asked  why  he 
had  been  brought  to  Siegburg,  and  could  not  recollect  any  circumstance  either  of 
his  journey  or  of  his  admission.  He  said  that  his  daughter,  eighteen  years  of  age, 
was  to  marry  the  son  of  the  first  banker  in  the  country;  and  when  he  was  made 
to  confess  that  his  daughter  was  only  four  years  of  age  and  her  betrothed  five,  he 
did  not  seem  greatly  surprised  at  it.  He  wrote  home  that  his  wife,  his  brother- 
in-law  and  the  relations  of  his  wife  had  been  carried  off  to  hell  by  the  devil;  that 
God  had  offered  him  a  high  position  in  London;  that  he  had  forwarded  his  watch 
and  his  uniform  to  Mexico,  etc. 

Afterwards  he  began  to  say  that  he  was  the  Prince  of  Neuchatel,  and  that  he 
was  about  to  have  conferred  upon  him  the  order  of  the  Holy  Spirit.  When  I 
tried  to  show  him  the  absurdity  of  his  remarks,  he  took  no  heed  and  continued 
his  talk.  He  one  day  secretly  wrote  to  his  agent,  begging  him  to  say  if  it  were 
not  true  that  he  was  Prince  of  Neuchatel,  and  to  forward  to  him  the  newspaper 
containing  the  account  of  his  nomination.  At  the  same  time,  he  charged  his 
friend  to  buy  for  him  a  new  house  at  75,000  florins,  etc. 

After  many  alternations  of  calm  and  rationality,  with  new  manifestations  of 
monomania,  the  patient,  under  the  employment  of  digitalis,  bleeding,  etc.,  re- 
mained for  six  months  without  showing  any  appreciable  symptoms  of  insanity. 
But  soon  he  fell  into  a  state  of  intellectual  weakness  and  confusion  of  thought, 
and  eight  days  after  his  dismissal  he  was  brought  back  again,  and  the  malady 
assumed  the  very  same  character  as  formerly.  He  was  afterwards  removed  to 
an  institution  for  chronic  cases.     (Jacobi,  '  Beobachtungen, '  etc.,  i.,  1830,  p.  295.) 

EXAJVIPLE  XXXIX.— Melancholia;  an  act  of  violence  in  consequence  of  melan- 
cholic delirious  conceptions;  aftenvards  monomania.— M..  A— ,  eet.  30,  of  a  very 
lively  disposition;  very  gay;  had  always  had  his  own  will  from  the  earliest  years. 
He  is  sensitive  to  any  lack  of  respect  shown  in  company,  and  has  the  ambition  to 
pass  for  a  person  of  high  importance.  He  likes  violent  exercise,  such  as  the  chase 
and  fencing.  He  is  vexed  when  he  cannot  exhibit  a  great  show.  From  his  birth 
to  his  fifteenth  year  he  was  subject  to  convulsions.  At  six  years,  he  had  a  sharp 
inflammation  of  the  brain,  which  was  cured  at  the  end  of  ten  days;  at  twelve,  he 
had  inguinal  hernia;  later,  he  had  inflammation  of  the  throat  with  delirium. 
During  his  infancy  he  was  often  exposed  to  alarming  incidents,  living  at  that 
time  in  midst  of  the  events  of  La  Vendee.  Since  that  time  M.  A—  never  ceased 
to  be  subject  to  panics  of  fear.  Arbitrary  and  violent  acts  exercised  towards  him 
in  time  of  trouble  contributed  to  fortify  his  tendency  to  alarm.  Nevertheless,  his 
constitution  got  stronger  at  the  time  of  puberty. 

A—,  after  having  fatigued  himself  with  reading,  isseized  by  a  love  of  study,  and 
is  convinced  that  an  attempt  is  about  to  be  made  upon  his  life.  Already  he  feels  the 
terrible  effects  of  poison.  He  dreads  all  who  approach  him,  except  his  parents, 
who  are  condemned  to  suffer  the  same  fate  with  himself.  He  beUeves  he  sees 
and  hears  people  armed  with  poignards  and  air-guns,  which  have  been  distri- 
buted for  the  purpose  of  killing  him.  If  he  walks  in  the  garden,  he  comes  back 
immediately,  saying  that  he  heard  a  bullet  whistle  past  his  eai".     Sometimes  he 


STATES    OF    MENTAL    EXALTATION.  221 

indulges  in  excessive  laughter,  and,  when  asked  why,  he  answers  that  he  hears 
sounds  out  of  which  he  makes  words  that  excite  his  laughter.  He  would  fain 
persuade  those  around  that  they  hear  the  same  sounds  as  he  does.  He  is  con- 
scious that  he  is  reckoned  mad;  he  hears  every  instant  some  one  crying  near  him, 
"  Madman!  madman! "  He  often  asks  his  parents  whether  his  eyes  are  not  fixed 
or  haggard.  Often,  after  a  meal,  he  raves  and  feels  himself  oppressed.  While  in 
an  inn  at  D — ,  a  barber  who  came  to  shave  him  bent  down  to  gather  something. 
Without  any  previous  altercation,  A —  tired  a  pistol  at  him  and  fractured  his  arm. 
Everything  seemed  to  show  that  he  mistook  the  unfortunate  man  for  an  assassin. 
After  that  fit  of  madness,  A —  remained  five  days  without  drinking,  eating,  or 
going  to  bed.  After  this,  he  recovered  his  sleep.  A —  is  naore  sane  and  calm;  he 
eats,  although  always  possessed  by  fears. 

He  was  now  put  under  my  charge.  The  countenance  of  the  patient  is  ex- 
tremely changeful  and  animated;  his  bearing  proud  and  haughty.  During  the 
first  days  he  I'efuses  every  kind  of  food.  He  will  not  have  his  beard  trimmed. 
He  does  not  sleep.  The  bowels,  in  spite  of  tepid  baths,  continued  for  some  length 
of  time,  remain  constipated. 

A —  pretends  to  be  the  first  man  of  genius  in  the  world,  and  attempts  are  made 
on  his  life  through  fear  that  he  may  become  Lord  of  the  universe.  He  is  Apollo, 
Cassar.  In  virtue  of  his  twofold  title,  he  expects  and  requires  all  the  world  to 
obey  him.  He  is  ashamed  that  the  loftiest  reason  should  be  so  confounded  with 
insanity.  A —  writes  to  all  the  men  who  occupy  the  highest  positions,  even  to  the 
king  himself.  Every  moment  he  expects  orders  to  set  him  at  liberty.  He 
threatens  me  with  all  the  weight  of  his  authority,  the  moment  he  shall  be  at 
liberty.  Meanwhile  he  asks  for  an  advocate  and  a  sheriff's  officer.  He  alone  is 
master;  no  one  has  any  authority  over  him.  He  answers  disdainfully  questions 
addressed  to  him;  very  often  he  does  not  deign  to  answer  at  all. 

It  is  quite  impossible  to  persuade  this  patient  that  he  is  the  sport  of  his  own 
disordered  fancy,  and  that  his  condition  demands  medical  treatment.  People 
wish,  he  says,  to  turn  his  head  with  their  remedies;  but  it  is  of  no  use,  they  will 
not  succeed.  Gentleness  and  persuasion  are  powerless.  When  it  is  needful  that 
he  should  bathe  or  have  a  blister  applied,  it  can  only  be  done  by  a  great  show  of 
force.  Many  times  thei^atient  is  calm;  he  talks  well,  is  amiable,  plays  at  several 
sports,  and  manifests  no  symptoms  of  insanity;  the  functions  of  the  organism 
present  no  disorder.     (Esquirol,  '  Geisteskrankheiten,'  von  Bernhardt,  ii.,  p.  8.) 

Example  XL. — Description  given  by  a  monomaniac  of  his  condition.  (Exalted 
emotions  of  various  kinds  excite  varying  ideas  of  illustrious  personalities.) — A 
poor  clergyman,  whom  the  too  rigorous  observance  of  his  vows  had  rendered 
insane,  related  his  history  in  the  following  manner: — "  Having  gone  to  a  house 
where  I  was  called  on  some  work  of  benevolence,  at  the  entrance  of  the  chamber 
into  which  I  was  introduced,  in  glancing  towards  two  women,  they  made  an  im- 
pression upon  my  sight  and  imagination  so  lively,  that  they  seemed  to  me  to  have 
been  illumined  as  if  they  had  been  electrified.  Ignorant  of  the  cause  of  so  singular 
a  phenomenon,  I  attributed  it  to  satanic  agency,  and  left.  When  I  had  got  out 
of  the  house  and  away  from  the  objects  which  had  so  strongly  affected  me,  I 
became  calm;  but  during  the  day,  having  encountered  other  women,  I  had  the 
same  distraction  and  the  same  illusion.  The  following  day,  being  on  a  journey, 
it  seemed  to  me  several  times  that  the  carriage  in  which  I  was  seated  was  about 
to  be  overturned,  which  caused  me  to  cry  to  the  people  in  charge  of  it  to  hold  it 
up.  But  the  false  alarms  causing  them  to  laugh,  I  knew  too  well  what  that 
meant.  There  was,  nevertheless,  a  disorder  and  derangement;  but  my  error  lay 
in  attributing  this  derangement  to  external  objects,  whereas  it  was  in  the  organs, 
and  in  the  confusion  of  sense  occasioned  by  my  having  never  read,  seen,  or 
experienced  any  similar  circumstance.  On  approaching  a  little  town  which  lay 
on  our  route,  and  having  seen  several  women,  they  caused  me  the  same  trouble 
and  the  same  illusions  as  those  wliom  I  had  seen  in  the  town.  Arrived  at  the 
inn,  I  had  dinner.  The  bread  and  wine,  as  well  as  everything  around,  seemed 
confused  and  about  to  be  overturned.  Then,  persuaded  that  a  satanic  power  ac- 
companied me  everywhere,  I  left  the  inn  hurriedly,  telling  the  innkeeper  at  the 
same  time  that  I  thought  he  had  a  hand  in  it,  and  I  entered  the  carriage  again. 
There,  fixing  my  attention,  as  far  as  the  agitation  of  fancy  and  feeling  would 
allow,  on  my  adventures  of  the  previous  evening  and  of  to-day,  I  was  confirmed 
in  the  opinion  by  the  fables  of  Ribadeneyra,  which  represent  the  hermits  as 
continually  besieged  by  demons.  The  words  of  St.  Paul,  where  he  says  that  it  is 
not  only  against  flesh  and  blood  that  we  have  to  fight,  but  agr.ijst  spiritual 
powers  as  well,  could  not  escape  me,  and,  arguing  from  that,  I  recognized  no 


222  STATES    OF    MENTAL    EXALTATION. 

other  cause  of  my  trouble  and  illusions  except  the  possession  of  a  demon,  and  I 
resolved  in  consequence  to  make  war  against  him  by  fasting,  prayer,  and  exor- 
cism. .  .  . 

"  My  activity  having  been  changed  into  warlike  fuiy,  the  image  and  remem- 
brance of  those  warriors  whose  history  and  character  had  most  strongly 
impressed  me  in  my  childhood  presented  themselves  to  me.  Then,  my  imagina- 
tion transporting  me  into  all  the  combats  and  assaults  of  which  I  had  read  the 
history ,  I  wished  to  represent  these  various  characters.  I  tried  those  of  Alex- 
ander, of  Acliilles,  and  of  Henry  IV.;  and  with  the  first,  to  wliom  I  likened 
myself  so  far  as  to  believe  that  I  possessed  his  appearance,  his  name,  and  to  be 
himself,  I  conquered  at  Arbela;  I  laid  siege  to  Tyre,  and  carried  its  ramparts  by  as- 
sault. While  I  represented  the  character  of  Alexander,  the  image  of  the  Tyrians 
whom  the  conqueror  caused  to  be  suspended  on  crosses  along  the  bank  of  the  sea 
came  to  my  imagination.  Seized  with  indignation  and  horror  at  that  spectacle,  I 
detested  the  character  of  the  Macedonian  hero,  and  I  no  longer  desired  to  be  that 
monster:  but  fixing  my  attention  upon  the  sad  victims  of  his  cruelty,  I  entered 
into  the  feelings  of  the  unfortunate  men,  and  was  as  sad  because  of  them  as  if  they 
had  been  beside  me.  During  a  second  attack  of  warlike  fury,  it  took  my  fancy  to 
assume  the  character  of  Achilles.  I  fancied  myself  binding  on  his  armor;  I 
assumed  his  voice  and  courage;  I  addressed  to  the  Trojans  words  of  insult  and 
defiance.  Then  driving  before  me,  overthrowing  and  putting  to  flight  the 
battalions,  as  it  seemed  to  me,  I  found  myself,  of  a  sudden,  at  the  gates  of  the 
palace  of  Priam.  Then,  by  the  confusion  and  wandering  of  an  imagination 
which  produced  images,  the  characters  of  wliich  were  dim  and  badly  defined, 
passing  rapidly  from  the  character  of  Achilles  to  that  of  Pyrrhus,  or  rather,  con- 
founding the  person  of  the  father  with  that  of  the  son,  and  strongly  impressed 
by  the  pictvire  which  Virgil  makes  of  the  latter,  believing  myself  to  be  the  hero, 
I  got  hold  of  the  four  pillars  of  my  bed,  and  I  threw  them  vigorously  against  the 
door  of  my  room,  which  I  dragged  from  its  hinges  and  carried  to  a  distance  of 
four  paces  off.  Transported  with  joy,  excited  by  the  shock  and  by  the  crash,  I 
shouted,  '  Troy  is  fallen!  the  palace  of  Priam  is  no  more! ' 

"  My  parents,  who  knew  nothing  of  what  ailed  me,  followed  the  course  of 
binding  my  body  and  shackling  my  hands.  Good  God!  what  sufferings  I  en- 
dured! What  a  resolution  was  accomplished  all  at  once  in  my  imagination! 
Fallen  from  the  liigh  degree  of  fortune  to  which  I  had  raised  myself — downcast, 
overwhelmed — I  looked  upon  my  chains  and  my  prison  with  horror  and  trembling, 
and  I  felt  a  burden  of  the  most  terrible  despair.  Having  fallen  asleep,  my 
imagination  was  aasailed  by  the  most  fearful  images.  I  thought  I  saw  Ancient 
Rome  rising  from  beneath  its  ruins,  opening  its  tombs,  and  presenting  to  my 
eyes  the  skeletons  of  tlie  most  famous  warriors  invested  in  armor,  the  shape,  the 
variety,  the  antiquity,  and  the  rust  of  which  constituted  a  horrible  sight.  That 
spectacle  impressed  my  imagination  so  strongly,  that  I  remained  for  a  long  time 
without  being  able  to  fix  my  attention  to  any  object  or  piece  of  iron  without 
extreme  horror,  which,  passing  into  my  very  senses,  affected  my  sense  of  smell 
with  a  sort  of  stench  of  iron  and  brass — a  disagreeable  odor  which  troubled  me 
for  many  days.  After  that,  my  imagination  got  the  better  of  me,  and,  causing 
me  to  traverse  the  heaps  of  ruin,  which  appeared  to  crumble  under  my  feet  and 
to  threaten  my  head,  it  led  me  to  the  gates  of  the  temple  of  the  god  of  war.  I 
thouglit  I  saw  these  gates  open,  and  heard  them  grind  upon  their  hinges  with  a 
horrible  noise.  I  saw  the  god  in  midst  of  his  temple,  and,  by  a  cruel  trick  of 
imagination,  I  believed  myself  a  monster  dripping  with  blood  and  carnage,  and 
laden  with  chains.  The  state  I  was  in,  bound  and  in  irons,  favored  that  iflusion, 
perhaps  caused  it  to  spring  up.  I  imputed  this  frightful  treatment  to  the  in- 
humanity which  I  fancied  to  have  been  exhibited  towards  the  person  of  Hector. 
Nevertheless,  a  moment  afterwards,  by  a  return  of  that  reflective  power  of  which 
I  seemed  so  little  capable,  sounding  my  feelings  and  finding  them  completely 
opposed  to  this  feature  of  inhumanity,  I  disavowed  and  abhorred  the  cruelty  of 
Achilles,  and  passing  immediately  to  feelings  of  the  tenderest  pity  and  compas- 
sion, I  deplored  the  fate  of  the  Trojan  hero.  I  cried,  or  believed  myself  to  cry, 
'  Oh!  Hector!  dear  Hector!  why  may  I  not  collect  thy  scattered  limbs,  to  bathe 
them,  to  warm  them  with  my  tears,  and  to  restore  them  to  life! '  As  I  spoke 
these  words,  I  shed,  in  reality,  a  flood  of  tears. 

"  The  feeling  of  these  gentle  passions  brought  me  back  to  peace  and  tranquil- 
lity, which  induced  my  parents  to  restore  me  to  liberty.  I  found  nothing  so  deli- 
cious as  these  first  moments.  It  seemed  to  me  that  all  nature,  formerly  a  captive, 
had  bursts  its  bonds,  and  enjoyed  with  me  the  charms  and  advantages  of  liberty. 


STATES    OF    MENTAL,   EXALTATION.  223 

I  took  the  character  of  a  peaceful  king;  I  fancied  that  I  fostered  and  exercised  in 
my  imaginary  dominion  all  the  arts,  all  the  sciences — painting,  sculpture,  archi- 
tecture, geometry,  etc.  I  drew,  I  made  plans  of  apartments,  which  greatly 
amused  me:  I  had  so  correct  an  eye,  and  so  firm  a  hand,  that,  without  any  other 
instruments  than  were  at  hand,  I  traced  images  on  the  ground  or  on  the  parti- 
tions of  my  room  with  extraordinary  accuracy.  My  parents  and  other  simple 
people,  surprised  at  seeing  me  express  in  such  a  happy  way  several  features  of 
talent  which  they  knew  I  never  before  exhibited,  imagined  there  was  something 
supernatural  in  it. 

' '  The  disposition  which  possessed  me  gave  to  my  senses  a  quietness,  and  to  my 
intelligence  a  penetration,  and  to  my  soul  a  grandeur  and  an  elevation,  which 
made  me  an  extraordinary  man.  I  seemed  to  read  the  heart  of  people  who  ap- 
proached me;  I  unfolded  their  character  with  astonishing  sagacity,  and,  uninflu- 
enced by  any  consideration,  I  described  it  with  justice  and  precision.  This  gave 
occasion  to  a  priest,  who  came  to  see  me  sometimes  in  my  illness,  to  tell  my 
parents  quite  seriously  that  I  was  possessed  by  the  spirit  of  Pytho,  the  same  that 
St.  Paul  drove  from  the  spirit  of  a  girl,  and  mention  of  which  is  made  in  the  Acts 
of  the  Apostles. 

"  It  may,  perhaps,  surprise  people  that  I  have  been  able  to  remember  so  many 
things  and  circumstances:  but  my  imagination  was  so  active,  that  every  object 
impressed  itself  there,  or  rather  engraved  itself  in  characters  of  fire;  and  many 
things  which  formerly  only  touched  it  slightly  when  I  was  in  health,  have  since 
that  time  become  much  more  actual."  (Leuret,  '  Fragmens,'  etc.,  Paris,  1834,  p. 
282.) 

Example  XLI. — Attacks  of  monomia,  of  the  nature  of  exaggeration  of  the 
sexual  instinct ;  rational  self-defence  of  the  patient.  {Folic  raisonnante,  ivith  a 
monomaniacal  tinge.) — A  certain  D —  was  arrested  several  times  in  Paris,  and 
placed  on  eight  different  occasions  in  an  asylum,  and  always  for  the  same  reason. 
He  wrote  to  ladies  in  the  highest  society  obscene  letters;  placed  himself  in  their 
path,  or  called  at  their  houses.  He  addressed  to  Madame  Bonaparte,  to  a  Madlle. 
Beauharnais,  and  to  a  multitude  of  duchesses,  princesses,  and  ladies  at  court, 
letters  written  in  a  style  of  revolting  obscenity,  which  he  named  heroic  poems. 
His  manner  of  conversation  was  otherwise  stamped  with  such  calmness,  and  had 
such  an  appearance  of  reason,  that  people  hesitated  several  times  to  call  him  mad. 
Nevertheless,  the  reality  of  his  insanity  was  established  in  a  report  made  by  Marc, 
Esquirol,  and  Ferrus.  Here  is  the  requisition  which  he  wrote  one  day  to  obtain 
his  liberty : 

"Five  weeks  ago  I  was  arbitrarily  arrested,  and  I  am  still  detained  in  the 
prison  de  la  Force,  in  spite  of  a  scandalous  violation  of  right  towards  an  honor- 
able man,  well  known  by  his  loyalty  and  imperturbable  reason,  and  for  his  irre- 
proachable conduct  in  all  respects.  I  was  walking  on  the  Tuesday  alone,  between 
two  and  three  o'clock,  in  the  Champs-Elysees,  when,  by  a  singular  fatality, 

Madame came  walking  herself — a  circumstance  which  almost  never  happens, 

I  believe.  She  was  accompanied  only  by  an  equerry,  an  oflScer,  and  a  lady. 
Hardly  had  I  seen  her  than  I  held  myself  at  a  respectful  distance  in  the  cross- 
walks of  the  great  avenue  where  she  was.  Thus  I  was  always  at  a  distance  of 
more  than  fifty  paces  during  her  promenade,  which  lasted  about  a  quarter  of  an 
hour,  although  the  public  did  not  seem  at  all  to  importune  her  in  surrounding  her 
during  her  walk,  or  in  gathering  round  her  carriage,  when  she  mounted  at  the 
extremity  of  the  Champs-Elysees,  on  the  side  of  the  Place  Louis  XV.  As  for 
myself,  at  that  instant  I  was  more  than  a  hundred  paces  off. 

' '  How  greatly  was  I  astonished  to  see  the  first  equerry  forbear  getting  into  the 
carriage  to  come  to  me  with  the  officer — to  me,  who  was  alone,  solitary,  and  far 
from  help  !  I  could  not  believe  that  it  was  to  lay  wait  for  me  on  the  public  road. 
Nevertheless,  it  was  so.  He  accosted  me,  and  holding  in  his  hand  a  paper  which 
resembled  a  letter  still  sealed,  he  accused  me  of  having  sent  it,  at  the  moment,  and 

in  the  crowd  formed  before  the  carriage  of  Madame ,  adding  that  that  letter 

was  libellous,  and  signed  by  my  hand.  I  answered  that  I  did  not  know  what  he 
meant,  and  that  I  took  M.  the  officer  to  witness  that  I  had  not  been  in  the  group, 
and  that  I  had  never  sent  any  letter  or  paper,  as  he  affirmed.  Then  I  told  him 
that  I  considered  him  a  slanderer.  Notwithstanding,  he  summoned  the  officer  to 
aiTest  me.  He  at  first  refused,  and  it  was  only  after  a  dispute  that  he  yielded  to 
his  solicitations.  I  believed  I  ought  not  to  resist  so  arbitrary  and  scandalous  an 
arrest,  and  made  it  a  duty  to  submit  with  confidence  to  the  -loyalty  of  govern- 
ment; all  the  more,  that  the  loyalty  of  my  well-known  character  ought  always  to 
deliver  me  from  any  kind  of  plot  formed  against  me." 


22-i  STATES    OF    MENTAL    EXALTATION. 

This  assurance,  adds  Marc,  seems  to  result  either  from  a  real  forgetfulness  of 
the  attacks  of  delirium  which  cause  M.  D—  to  take  pen  in  hand  by  inflaming  his 
amatory  enthusiasm,  or  from  a  system  of  denial  which  he  regards  as  useful  to  his 
interests.     (Marc,  "Die  Geisteskrankheiten,'  etc.,  von  Ideler,  i.,  p.  23.) 


STATES   OF    MENTAL   WEAKNESS.  225 


CHAPTER  III. 

THE  STATES  OF  MENTAL  WEAKNESS. 

§  145,  Under  this  section  are  comprehended  a  series  of  morbid  states 
of  mind  which,  although  presenting  great  differences  in  their  details, 
collectively  form  a  natural  group.  They  all  closely  resemble  each  other 
in  the  circumstance  that  (with  a  few  exceptions  to  be  afterwards  men- 
tioned) they  do  not  constitute  primary,  but  consecutive  forms  of  insanity, 
— that  they  continue  as  remnants  and  residues  of  the  forms  which  we 
have  already  been  considering  when  these  are  not  cured.  Further  they 
are  allied  in  this,  that  the  fundamental  mental  affection  no  longer  depends 
in  them,  as  in  melancholia  and  mania,  upon  ruling  emotions  which 
secondarily  involve  the  intellect,  but  the  disorder  of  the  intelligence  con- 
stitutes in  itself  the  fundamental  anomaly,  the  emotions  being  suppressed 
or  entirely  wanting  (§  29).  This  disorder  of  the  intelligence  either 
presents  the  decided  character  of  weakness,  which  in  dementia  proper  is 
manifested  in  the  sluggishness  of  thought,  the  want  of  normal  reproduc- 
tion of  ideas  (loss  of  memory)  and  their  healthy  association — it  may  pro- 
ceed to  total  abolition  of  all  the  mental  faculties,  with  which  there  is  also 
combined  weakness  of  the  emotions  and  will,  want  of  energy  or  com- 
plete loss  of  volition,  and  dulness  of  the  emotions,  bluntnessof  the  moral 
nature  arising  from  the  absence  or  superficiality  of  reactionary  power, — 
or  the  mental  weakness  is  in  a  measure  concealed  by  the  predominance  of 
certain  delirious  conceptions,  whose  obstinate  persistence  is  significant  of 
all  that  remains  of  mental  power,  and  behind  which  all  consciousness  is 
but  an  empty  void.  Out  of  this  vacancy  no  ideas  can  any  longer  arise 
which  might  counteract  and  overthrow  the  delusion;  although  the  patient 
is  no  longer  governed  by  a  dominant  sentiment,  still  the  delirium  remains 
persistent,  owing  to  vacuity  of  thought,  which  ordinarily  does  not  merely 
affect  the  limited  sphere  of  the  fixed  delirious  conceptions,  but  is  only 
the  partial  appearance  of  a  general  diminution  and  destruction  of  all  the 
mental  processes.  Thus  we  consider  that  partial  dementia  ought  to  be 
comprehended  under  the  states  of  mental  weakness. 

In  these  states  we  no  longer  recognize  the  changeability  of  the  forms 
which  we  have  hitherto  been  considering,  nor  that  activity  of  the  morbid 
process  in  whicli  the  play  of  active,  healthy  mental  function,  mental 
elaboration  and  combination,  is  so  plainly  recognizable  (i)articularly 
according  to  the  law  of  causality).  Here  the  false  ideas,  in  so  far  as  they 
are  not  taken  over  from  a  former  period,  depend  in  great  part  rather  on 
incoherence  and  weakness  of  thought,  or  on  partial  dementia,  upon  hallu- 
cinations not  depending  on  tlie  emotions  and  on  an  extension,  constantly 
more  penetrating,  of  former  delirious  ideas  relating  to  the  entire  sphere 
of  perception.  All  these  morbid  states  (again  with  a  few  exceptions), 
when  not  cut  short  by  death,  are  very  chronic  in  their  course,  and  gener- 
ally are  capable  only  of  one  kind  of  change  or  modification — namely,  in- 
cr  ease  of  the  mental  weakness.    Nevertheless,  they  often  remain  quite  sta- 


226  STATES    OF    MENTAL    WEAKNESS. 

tionary  for  long  series  of  years  ;  they  no  longer  admit  of  complete  recov- 
ery. 

My  having,  in  the  first  edition  of  this  work,  classed  partial  dementia  with  the 
states  of  mental  weakness,  has  caused  a  great  deal  of  controversy.  But,  in  fact, 
it  can  be  placed  nowhere  else.  In  complete  dementia  we  have,  along  with  deli- 
rious conceptions  which  have  become  as  it  were  stereotyped,  a  decided  diminution 
of  the  moral  powers,  a  mental  decrepitude,  a  wreck  after  the  subsided  storrn. 
There  exists,  it  is  true,  between  this  terminal  point  and  the  primary  stages,  in 
many  patients  a  long  period  of  transition,  in  which  there  still  plays  around  several 
groups  of  deUrious  conceptions  remaining  over  from  these  primary  stages,  an 
active  mental  process.  In  this  the  delirium  becomes  in  part  modified  quite  in- 
voluntarily, in  part  elaborated  and  systematized  (§  44).  When  this  is  completely 
finished,  the  quite  stationary  period  commences,  in  which  the  delirium  consists 
only  in  a  repetition  of  the  fixed  residuary  ideas.  Those  states  of  transition  which 
still  permit  a  certain  change  of  the  morbid  mental  phenomena,  and  which  are 
numerously  represented  in  every  asylum,  are,  in  regard  to  classification,  a  source 
of  embarrassment  to  the  beginner.  He  may,  without  hesitation,  keep  to  the 
principal  classes  which  have  been  here  established,  but  must  consider  that  some- 
times a  long  period  of  observation  is  necessary  to  determine  in  a  given  case  how 
much  is  still  activity  and  progress,  and  how  much  is  simply  residue.  Neumann 
('  Lehrb.  d.  Psychiatric,'  1859,  p.  70)  calls  what  we  designate  dementia,  "  recovery 
with  defect."  How  far  ' '  recovery  "  may  be  spoken  of,  or  rather  cannot  be  spoken 
of,  is  clear.  As  to  the  "de/ec<,"it  essentially  expresses  the  same  view  which 
prompted  me  to  class  dementia  amongst  the  states  of  mental  weakness. 

§  146.  The  states  of  mental  weakness  comprehend  two  great  groups — 
Chronic  Mania  and  Dementia.  In  regard  to  the  first,  we  refer  the  reader 
to  the  description  farther  on.  In  the  form  of  dementia  we  distinguish 
two  divisions — the  one  with  incoherence  of  the  ideas,  but  with  consider- 
able, although  merely  superficial,  activity  of  perception,  generally  with  a 
slight  degree  of  outward  agitation  (demence  agitee);  the  other  with  ex- 
treme sluggishness  of  perception,  even  to  complete  abolition  of  it,  and 
with  external  apathetic  calm  (demence  apathique).  In  this  division  we 
only  consider  that  form  of  dementia  which  is  acquired — that,  namely, 
which  occurs  in  individuals  who  have  been  formerly  mentally  healthy. 
We  shall  devote  a  special  chapter  to  that  form  which  is  congenital,  or 
which  arises  in  the  early  years  of  childhood — the  various  degrees  of 
idiocy. 

This  acquired  dementia,  considered  as  a  special  form  of  insanity,  may 
of  course  arise  primarily— that  is,  without  having  been  preceded  by 
another  form  of  mental  disease,  or  other  cerebral  disease  of  a  different 
nature,  as  in  the  case  of  the  mental  weakness  of  advanced  life  or  prema- 
ture decrepitude,  primary  atrophy  of  the  brain,  intracranial  tumors,  etc. 
As  to  the  cases  described  by  many  authors  as  acute,  curable,  primary  de- 
mentia, the  great  majority  of  them  certainly  belong  to  melancholia  with 
stupor,  in  the  description  of  which  we  have  already  called  attention  to  the 
readiness  with  which  it  may  be  confounded  with  actual  mental  weakness, 
and  to  the  distinctive  signs  of  both  forms.  Nevertheless,  it  cannot  be 
doubted  that  there  exist  intermediate  states  between  melancholic  stupor 
and  actual  dementia,  and  also  decided  cases  of  primary,  acute,  and  cur- 
able dementia;  in  proof  of  which  we  shall  cite  an  interesting  example  of  a 
case  in  which  the  dementia  was  probably  owing  to  ojdema  of  the  brain 
from  pressure  on  the  cervical  veins. 

Example  ^lAl.— State  of  dementia  of  several  weeks'  duration,  and  without 
subsequent  recollection  of  it,  caused  by  an  attempt  at  straiigulation.—A.  prisoner, 
set.  25,  strongand  healthy,  hanged  himself.  Almost  immediately  after  thecuttmg 
down  of  the  body,  it  showed  signs  of  life;  consciousness  returned.  The  patient 
gave,  apparently  quite  calmly  and  sensibly,  the  history  of  his  life  and  his  motive 


STATES    OF    XENTAL,    WEAKNESS.  227 

for  the  deed  (weariness  of  life).  On  the  following  day  he  was  tranquil  and  spoke 
little;  on  the  third  day  he  spoke  none.  The  countenance  was  fixed,  the  eyes 
rolling  and  injected ;  the  temporal  and  masseter  muscles  and  those  of  the  eyes  were 
convulsed;  the  face  immovable  and  lifeless,  like  that  of  a  statue.  No  sensorial 
impressions  appeared  to  be  perceived,  but  a  very  loud  sound  caused  slight  con- 
tractions of  the  facial  muscles;  he  went  about  and  ate  without  expressing  desire 
or  sensation.  After  three  weeks  had  elapsed,  the  patient  was  taken  to  an  asylum ; 
and  after  a  few  more  weeks  he  awakened.  He  remembered  perfectly  well  the 
time  and  the  circumstances  which  had  preceded  the  hanging  until  the  onset  of 
loss  of  consciousness,  and  described  the  violent  struggle  in  his  mind  between  the 
resolve  and  the  fulfilment  of  the  deed,  and  the  sensations  in  the  moment  of  hang- 
ing— ringing  of  the  ears  and  stars  in  the  eyes.  From  this  time  to  the  hour  of  liis 
awaking  in  the  asylum,  all  recollection  of  his  personal  existence  was  wanting; 
even  the  animation  after  the  hanging  and  the  temporary  possession  of  conscious- 
ness were  quite  unknown  to  him.  The  second  awaking  took  place  suddenly:  one 
day,  in  the  court,  the  idea  of  the  buildings  around  was  awakened  in  him,  and  this 
called  forth  remembrances  of  other  similar  objects.  From  that  hour  the  mental 
functions  and  the  general  health  rapidly  became  re-established.  (Meding,  iu  Sie- 
benhaar,  '  Magazin  fiir  die  Staatsarzneikunde,'  i,  1842.) 

But  far  more  frequently  acquired  dementia  originates  consecutively, 
that  is,  after  the  symptoms  of  another  severe  cerebral  disease  (epilepsy, 
acute  meningitis,  typhoid  cerebral  affections,  etc.),  and  especially  wlien 
other  forms  of  insanity  have  preceded  it.  It  constitutes  then  the  sad  end 
of  all  mental  diseases  which  remain  uncured — melancholia,  mania,  and 
monomania.  What  is  very  remarkable,  senile  dementia  even  isnotunfre- 
quently  preceded  by  a  period  of  exaltation — a  short  maniacal  stage, 
characterized  by  great  psychical  irritability,  a  newly  awakened  tendency 
to  activity,  reappearance  of  the  sexual  desires  (wishing  to  marry,  etc.), 
and  a  craving  for  alcoholic  drinks:  this  is  then  followed  either  by  rapid 
psychical  collapse,  or  short  periods  of  exaltation  alternate  several  times 
with  the  increasing  mental  weakness.  During  convalescence  also,  espe- 
cially from  violent  mania,  there  not  unfrequently  occurs  a  condition  of 
profound  mental  weakness:  this  state  bears  the  same  relation  to  true  de- 
mentia that  great  and  long-continued  fatigue  does  to  actual  paralysis. 

It  is  not  at  all  unusual,  although  hitherto  it  has  been  very  little  at- 
tended to,  to  observe  a  mental  state  characterized  by  moderate  weakness 
occasionally  ensue  after  apparent  recovery  from  other  forms,  and  to  re- 
main persistent.  In  individuals  who  have  recovered  in  this  wa},  the 
sentiments  regain  their  former  calm;  they  can  also  again  think  and 
judge  in  a  formally  correct  manner — the  memory  is  little  or  not  at  all 
disturbed — their  conversation  is  quite  coherent  and  rational.  But  they 
are  no  longer  the  same  persons;  it  seems  as  if  their  mental  individuality 
had  been  deprived  of  its  best  and  most  valuable  qualities,  the  more  deli- 
cate moral  and  aesthetic  sentiments,  interest  in  the  higher  mental  aims  of 
life,  which  form  the  beauty  and  the  nobleness  of  human  nature.  Their 
thoughts  and  efforts  move  henceforth  within  a  limited  circle,  in  the 
sphere  of  the  immediate  wants  and  requirements;  and  while  they  conduct 
themselves  rationally,  perhaps  with  a  degree  of  activity  in  this  circle,  all 
the  spiritual  and  ideal  concerns  of  life,  all  consideration  or  desire  of 
them,  are  foreign  to  them.  These  persons  might  be  regarded  as  perfectly 
sane — since  there  are  many  individuals  who  are  all  along  of  this  dis- 
position— if  we  had  not  been  acquainted  with  their  former  life,  and  if,  in 
many  cases,  in  the  physiognomy  and  whole  demeanor,  a  marked  change 
to  idiotic,  even  animal-like  expressions,  was  not  recognized.  They  are 
further  capable  of  simple  meclianical  employments,  in  the  performance 
of  which  tliey  show  care  and  intelligence;  for  themselves  they  desire 
nothing  more  than  suffices  to  satisfy  simple  material  wants.     Should  such 


228  STATES    OF    MENTAL    WEAKNESS. 

individuals  be  permitted  to  leave  the  asylum  and  return  to  ordinary  life, 
they  run  a  great  risk  of  nevv  and  severe  attacks  of  insanity,  or  of  gradually 
passing  into  confirmed  mental  weakness.  In  the  asylum  they  often  for 
years  enjoy  a  life  of  relative  health,  calm,  and  useful  employment. 

Such  states  may  be  regarded  as  the  mildest  forms  of  dementia.  In 
all  liigher  degrees  the  patient  ceases  to  present  any  appearances  of 
convalescence,  and  the  increasing  mental  dulness  is  not  restricted  to  the 
finer  and  more  delicate  faculties.  Sometimes  the  whole  mental  life 
again  assumes  the  character  it  had  in  childhood,  in  which  most  strikingly 
the  capacity  of  abstract  thought  is  lost;  in  many  forms,  again,  a 
certain  superfical  and  incoherent  activity  and  mobility  of  thought  still 
remains.  The  absence  of  all  serious  thought — because  comparatively 
few  and  limited  masses  of  ideas  are  present — the  pleasure  in  trifles  and 
toys  which  afford  material  for  superficial  fantasy,  and  the  unmasked  and 
unrestrained  manifestation  of  the  disposition  actually  present  (laughing, 
jumping,  weeping)  observed  in  many  of  these  states,  cause  them  closely 
to  resemble  the  state  of  childhood.  Many  of  these  patients  also  have  to 
be  treated  and  guided  like  helpless  children;  they  may,  however,  by  kind- 
ness or  severity  be  kept  at  light  mechanical  employments,  and  by  meth- 
odical regulation  and  care  kept  from  manifesting  the  incoherence  and 
confusion  of  their  ideas,  and  often  for  a  long  time  preserved  from  more 
profound  mental  decay. 

These  cases  of  chronic  mania  and  dementia  constitute  the  vast  major- 
ity of  the  insane,  and  institutions  devoted  to  chronic  cases  are  almost 
•exclusively  inhabited  by  them.  It  would  be  well  if  our  psychological 
knowledge  of  these  states  were  only  in  a  degree  somewhat  approaching 
to  the  rich  opportunities  afforded  to  us  of  studying  them!  The  individ- 
ual varieties  are  here  still  greater  than  in  the  forms  Ave  have  already  con- 
sidered;  they  can  neither  be  enumerated  nor  described.  We  must  rest 
satisfied  with  stating  and  describing  several  principal  types. 

Section  I. — Chronic  Mania  {Die  Verrilchtheit;  La  Folie 

systematisee). 

§  147.  Under  this  term  are  comprehended  those  secondary  states  of 
insanity  in  which,  although  the  original  morbid  state  of  the  sentiments 
has  considerably  diminished  or  even  entirely  disappeared,  the  individual 
does  not  recover,  but  remains  affected  in  such  a  manner  that  the  delirium 
is  now  most  strikingly  exhibited  in  certain  fixed  delirious  conceptions 
which  are  cherished  with  especial  preference  and  constantly  repeated — 
always,  therefore,  a  secondary  disease  developed  out  of  melancholia  or 
mania.  We  consider  the  term  monomania  (§  45)  introduced  by  Esquirol, 
but  employed  by  him  in  an  essentially  different  sense,  especially  adapted 
designate  these  states,  provided  it  could  always  be  restricted  to  a  special 
form  of  mental  disease.  The  study  of  the  psychical  phenomena  in  these 
patients  seems  to  us  to  have  been  hitherto  much  neglected,  and  the  true 
nature  of  the  disease  to  have  been  observed  and  falsified  by  anecdotal 
conceptions.  We  shall  attempt  to  describe  what  we  have  learned  from 
actual  observation. 

Anomalies  of  Self -consciousness,  the  Desires  and  the  Will. — The  trans- 
ition of  melancholia  and  mania  with  delirious  conceptions  to  these 
states  always  takes  place  gradually.  The  state  of  negative  or  affirmative 
emotion  resulting  from  these  conditions  often  disappears  very  slowly,  os- 
cillating for  several  years:  a  chronic  state  of  modified  melancholia  or 


STATES    OF    MENTAL    WEAKNESS.  229 

maniacal  excitement,  howeyer,  often  remains  long  persistent;  after  a 
time  this  also  disappears,  leaving  behind  it  certain  delirious  concep- 
tions. According  as  the  emotional  excitement  becomes  weaker,  apparent 
reflection  gradually  returns;  in  place  of  incoherence  of  thought,  mental 
tension  or  convulsive  shock  and  suppressed  volition,  there  again  enters  a 
more  regular  flow  of  psychical  activity.  Gradually  there  is  re-estab- 
lished an  entire  or  partial  external  equilibrium,  as  with  the  disapperance 
of  the  morbid  emotions  the  mind  becomes  calm. 

But  this  is  no  longer  the  equilibrium  of  the  former  healthy  life.  Grad- 
ually a  new  intermediate  state  of  the  psychical  tonicity,  new  emotions 
and  a  new  character  are  developed:  the  patients  are  not  now  what  they 
formerly  were;  with  the  addition  of  one  or  two  erroneous  opinions  or  a  few 
delirious  conceptions,  they  are  thoroughly  changed.  This  radical  change, 
which  is  naturally  most  distinctly  manifested  where  the  general  melan- 
cholia and  the  maniacal  exaltation  have  now  entirelij  disappeared,  con- 
sists essentially  in  dulness  and  weakness  of  all  psychical  reaction — in  an 
absence  of  sentiment,  indifference,  and  diminished  energy  of  the  will. 
None  of  these  patients  are  any  longer  capable  of  tl>e  same  interest  in  the 
external  world,  the  same  love  and  the  same  hate,  as  formerly.  Friends 
and  relatives  may  die,  that  which  was  formerly  most  dear  to  them  may 
go  to  wreck,  the  most  joyful  event  may  happen  in  their  family — tliey 
will  experience  at  most  only  a  very  superficial  disagreeable  or  agreeable 
excitement,  or  they  will  quickly  turn  from  the  subject  as  from  some  un- 
welcome disturbance,  or  they  may  not  react  at  all.  Only  on  one  point 
can  the  psychical  tone  still  be  readily  ascertained  and  altered — can  emo- 
tions and  reactions  of  the  will  be  rapidly  called  forth:  if  we  touch  upon 
the  fixed  idea,  if  we  oppose  his  statements  by  arguments  or  his  pro- 
jects by  force,  the  patient  will  immediately  become  angry  and  violent:  if 
we  encourage  the  delusion,  he  will  at  once  rejoice. 

In  certain  cases  which  may  become  the  subjects  of  medico-legal  inquiry,  the 
total  dulness  of  sentiment  and  "thereby  perverted  reaction,  forms  one  of  the  most 
prominent  elements  of  these  .conditions;  they  present  a  species  of  quite  chronic 
fixed  moral  insanity,  which  might  be  designated  emotional  insanity.  The  prin- 
cipal though  by  no  means  the  only  examples  of  this  condition  are  to  be  found 
amongst  drunkards  who  have  become  insane  (see  §  41). 

Tlie  emotional  dulness  of  the  chronic  maniac  is  very  characteristically  mani- 
fested in  his  relations  to  the  asylum.  The  individuals  are,  almost  without  excep- 
tion, quite  contented  with  their  lot:  they  never  form  plots  (which,  owing  to  their 
number,  they  could  easily  do),  a  single  attendant  leads  them  like  a  flock  of  sheep; 
should  one  of  them  suffer  punishment  or  be  removed,  the  circumstance  does  not 
at  all  affect  the  others. 

§  148.  Emotional  states,  therefore,  are  still  possible,  but  only  one 
group  of  ideas  is  able  to  provoke  them.  The  ruling  disposition  is,  in- 
deed, on  the  whole,  one  which  corresponds  to  the  delirious  idea,  although 
in  a  weaker  degree;  and  in  the  higher  grades  of  partial  dementia  there 
often  prevails  so  entire  an  indifference,  that,  without  any  trace  of  emotion, 
the  patient  incessantly  declares  himself  to  be  the  ruler  of  the  world,  the 
possessor  of  all  in  heaven  and  earth,  God  himself,  etc.  The  psychical  re- 
react'on  on  all  excitation  other  than  that  which  is  directly  in  connection 
with  the  delusion  is  generally  very  feeble,  because,  on  the  one  hand,  per- 
ception, in  so  far  as  it  is  not  related  to  the  delusion,  has  considerably 
lost  its  energy  and  become  blunted;  and,  on  the  other  hand,  because  fre- 
quently many  masses  of  ideas  which  belong  to  the  former  life  of  the  pa- 
tient are  now  completely  dissipated,  forgotten,  or  no  longer  recognized 
by  him  as  his  own.     It  is  the  same  circumstance  which  in  the  sphere  of 


230  STATES    OF    MENTAL     WEAKNESS. 

the  intelligence  does  not  permit  the  patient  to  recognize  the  folly  of  his 
delusion.  The  relations  are  not  like  those  of  ordinary  life,  where  a  leading 
idea,  an  impelling  thought,  temporarily  obscures  and  suppresses  the 
other  ideas.  In  health  there  is  always  the  possibility  of  the  contrasting 
ideas,  doubt  and  hesitation,  arising.  But  in  chronic  mania,  although 
the  patient  is  no  longer  in  the  state  of  emotional  excitement  which  for- 
merly rendered  it  impossible  for  him  to  recognize  the  error  of  his  ideas — 
although  he,  indeed,  sometimes  reasons  with  formal  correctness  upon 
certain  points — yet  he  is  no  longer  capable  of  doubting  the  possibility  of 
his  delusion.  That  the  fixed  ideas  cannot  meet  any  disturbance  in  their 
fourse,  is  owing  to  tlie  circumstance  that  no  counterpoise,  no  inward  op- 
position resists'them;  and  this  appears  to  depend  quite  as  much  upon  a 
general  weakening  of  the  former  intelligence,  as  upon  the  disappearance 
of  certain  series  of  healthy  ideas.  Thus,  the  cause  of  the  impossibility 
of  recognizing  the  delusion  as  such,  and  the  general  indifference  and  di- 
minished psychical  reaction,  may  both  be  founded  upon  the  same  psychi- 
cal defects. 

It  is  the  same  with  the  emotions  and  the  will.  So  long  as  slight  mel- 
ancholia and  emotional  excitement  remain,  volition  presents  the  general 
character  of  these  states;  and  there  are  then  observed,  sometimes  a  one- 
sided persistence  in  a  single  negative  direction  (for  example,  a  continual 
tendency  deliberately  to  destroy  inanimate  objects — to  tear  the  clothes, 
pieces  of  paper,  etc.),  sometimes  a  restless  energy  in  the  direction  of  the 
delirious  conceptions,  sometimes  transient  maniacal  attacks.  Afterwards, 
however,  there  also  appears  in  the  volition  a  mediate  or  higher  degree 
of  general  Aveakness;  some  can  continue  the  mechanical  employments  to 
which  they  were  formerly  accustomed,  as,  for  example,  Professor  Titel, 
who  believed  himself  to  be  the  Emperor  of  Kome,  and  continued  to  read 
his  course  of  lectures  in  the  College;  or  they  can  pursue  easy  manual  oc- 
cupations: but  there  is  no  longer  that  desire  for  healthy  activity,  and 
even  the  acts  corresponding  to  the  delirious  idea,  as  the  writing  of  letters, 
issuing  of  proclamations,  etc.,  gradually  become  less  energetic  and  more 
superficial;  while  in  the  most  confirmed  states  there  only  remains  the 
most  feeble  employment — the  amusing  themselves  with  pebbles,  rags, 
paper,  etc. 

All  sorts  of  capricious  desires,  such  as  are  also  observed  in  the  forms 
we  have  already  studied,  are  particularly  frequent  in  chronic  mania,  and 
become  fixed  habits.  Some  constantly  seek  to  work  amongst  water, 
others  would  be  always  pulling  off  their  boots,  others  manifest  a  special 
preference  for  certain  places  and  corners  where  they  may  always  be 
found:  some  will  not  speak;  others  scream,  sing,  declaim,  or  continually 
employ  themselves  in  daubing  the  walls;  some  rejoice  in  decorating 
themselves  with  straw,  rags,  and  trifles;  others  take  delight  in  allowing 
their  nails  to  grow  long;  while  others  again  are  always  perpetrating  mali- 
cious acts,  making  peculiar  gestures,  etc.  These  desires  have  often  a 
peculiar,  mysterious  significance  to  the  patient,  or  they  proceed  from  cer- 
tain frames  of  mind  connected  with  the  delusion;  at  other  times  tliey  are 
purely  automatic,  the  patient  himself  knows  no  cause  for  theui,  and  is 
angry  Avhen  questioned  regarding  them,  in  the  same  Avay  as  healthy  per- 
sons are  irritated  when  asked  the  reason  of  peculiar  habits,  such  as 
chewing  the  nails  or  making  unnecessary  movements  with  the  hands, 

etc. 

§  149.  Amongst  the  anomalies  of  thought  in  chronic  mania,  we  meet, 
in  the  first  jilace,  with  a  formal  change — namely,  a  sometimes  moderate, 


STATES    OF    MENTAL    WEAKNESS.  231 

sometimes  increased  degree  of  weakness  of  thought,  generally  accompanied 
by  loss  (forgetfulness)  of  great  series  of  ideas  which  formerly  belonged  to 
the  individual  in  health.  For  these  reasons,  no  clear  apprehension,  no 
healthy  mental  conception  is  now  possible  to  the  patient.  Some  may, 
indeed,  carry  on  a  pretty  rational  conversation,  but  generally  it  consists 
merely  of  current  phrases;  so  soon  as  actual  abstract  thought  is  required, 
they  show  their  incapacity  to  gi-asp  the  subject.  Eeal  acuteness  never 
exists  in  chronic  mania,  unless,  indeed,  the  occasional  curious  combina- 
tions of  thought  which,  occurring  abruptly  and  unex2)ectedly,  and  seem 
now  and  then  somewhat  surprising,  be  considered  as  such.  Generally, 
the  patient  cannot  fix  in  his  mind,  even  in  a  slight  degree,  any  idea 
winch  is  not  closely  connected  with  the  dominant  delusion;  he  deviates 
from  the  subject,  and  generally  reverts,  in  writing  even  more  than  in 
speaking,  to  that  circle  of  ideas  which  to  him  is  alone  actual  and  real. 
In  the  more  advanced  degrees,  this  weakness  of  perception  becomes  actual 
incoherence — a  casual  rising  of  images  and  thoughts  without  sense  or 
coherence,  only  loosely  connected  by  the  unity  of  the  fixed  ideas:  with 
this  chronic  mania  passes  into  dementia. 

We  have  already  seen,  in  a  former  chajDter,  how  the  separate  delirious 
conceptions  arise  in  melancholia  and  mania,  and  their  subject-matter  is 
there  indicated.  They  always  relate  to  the  special  personality  of  the 
patient,  to  his  position  in  the  world  or  relation  to  the  Deity,  although 
their  subject-matter  presents  essential  differences. 

Sometimes  they  are  exalted  maniacal  ideas  of  an  active  kind,  relating 
to  elevation  of  the  subject  and  his  domination  over  external  things — God, 
one  of  the  Holy  Trinity,  state  reformers,  kings,  learned  men,  prophets, 
ambassadors  from  God,  discoverers  of  perpetual  motion,  the  mother  of 
nature,  one  who  has  penetrated  all  mysteries  and  knows  the  elements  of 
all  things,  etc. 

Or  the  delirious  conceptions  relate  to  some  affliction,  to  domination 
by  external  things.  The  patients  believe  that  they  are  persecuted,  sur- 
rounded by  spies,  tormented  by  secret  enemies  who  employ  electricity 
against  them,  tormented  by  freemasons,  possessed  of  a  devil,  eternally 
damned,  robbed  of  their  most  valued  treasures,  etc.  Or  they  cherish 
fixed  delirious  conceptions  regarding  their  own  body;  they  are  dead; 
their  bones  are  made  of  glass,  of  butter;  they  harbor  strange  things  in 
their  body,  etc. 

From  the  different  characters  of  these  ideas  we  are  enabled  to  distin- 
guish chronic  mania  with  active,  exalted  (§  131)  delirium,  from  the  same 
with  passive,  depressed  delirium. 

The  more  limited  the  circle  of  these  delirious  conceptions,  tlie  more 
do  they  appear,  on  superficial  consideration,  to  be  simple  and  even  incon- 
siderable errors  of  judgment.  Buc  how  much  do  such  errors,  even  in 
the  most  favorable  case,  differ  from  those  mistakes  which  in  the  same 
proceed  from  deficient  knowledge!  A  long  series  of  psychical  disorders 
must  precede  them;  they  are  inwardly  developed  from  states  of  emotion. 
The  whole  personality  of  the  patient  is  identified  with  them;  he  can  neither 
cast  them  from  him  by  an  act  of  will,  nor  rid  himself  of  them  by  argu- 
ment; and  in  order  to  the  existence  of  the  delirium  in  this  mild  form, 
not  only  must  that  long  series  of  emotional  states  m  which  it  grew  have 
run  their  course,  but  there  must  also  remain  behind  a  deficiency  of  thought 
to  insure  its  existence. 

Above  all,  however,  the  partial  delirium  of  dementia  depends  not  so 
much  on  the  circumstance  that  the  false  ideas  of  the  patient  are  limited 


232  STATES    OF    MENTAL    WEAKNESS. 

to  one  subject,  as  on  this — that  he  always,  by  preference,  exjn'esses  one 
sole  and  leading  false  idea  which  constantly  pursues  him.  His  morbid 
thought  is  much  more  extended :  the  delirium  which  has  been  developed 
in  the  practical  sphere  of  the  affective  sentiments  extends  not  only  to  the 
neighboring  sphere  of  self-consciousnes,  where  it  disturbs  the  proper  esti- 
mate of  the  special  personality  and  its  relation  to  the  world,  but  it  also 
identifies  itself  with  all  the  theoretical  ideas  of  the  patient  and  gradually 
falsifies  all  his  thoughts.  Then  he  involuntarily  refers  everything  to  the 
delirium;  in  its  light  everything  is  viewed;  and  thus  he  cannot  fail,  in  the 
most  favorable  cases  (for  example,  in  simple  hypochondriacal  delirium), 
to  have  false  notions  and  views  of  life  which  were  formerly  quite  foreign 
to  him.  Where,  however,  there  exist  more  serious  false  ideas  concerning 
the  special  personality,  all  the  patient's  views  in  regard  to  the  external 
world  are  totally  perverted;  he  judges  everything  from  a  false  position 
and  from  wrong  premises;  and  where  there  is  most  form  and  logical  order, 
the  insanity  proceeds  frequently  to  a  comprehensive  and  sometimes  care- 
fully concealed  system  of  delusions,  in  which  all  the  relations  of  human 
intercourse,  all  moral  considerations — indeed,  the  whole  internal  and  ex- 
ternal organization  of  the  universe — are  mysteriously  expressed.  Some- 
times ordinary  language  is  not  sufficient  to  express  his  thoughts,  and  he 
invents,  at  least  to  express  the  delirious  ideas,  atotally  different  language, 
which  he  declares  to  be  the  primitive  language,  the  language  of  heaven, 
etc. ;  and  the  more  the  sensorial  impressions  are  obscured  by  hallucina- 
tions, and  the  inward  views  become  indistinct  and  displaced  by  confusion 
and  weakness,  the  more  do  these  states  pass  into  the  form  of  dementia. 

The  origin  of  these  prominent  delirious  conceptions  can  always  be  traced  to  a 
stage  of  melancholia  or  mania,  and  often  to  special  occurrences  during  these 
stages.  Should  the  fixed  idea  consist  in  the  delusion  of  being  some  illustrious 
personage,  their  behavior  when  opposed  by  the  arguments  of  reason  is  very 
remarkable.  Generally  the  patients  can  still  give  an  account  of  their  former 
life,  sometimes  they  even  admit  that  they  have  been  insane  (certainly,  however, 
only  from  hearsay,  and  they  then  understand  by  it  only  the  form  of  melancholia); 
often  they  narrate  the  more  minute  circumstances  of  their  change  (especially 
hallucinations),  but  generally  they  do  so  very  indistinctly.  They  remark  that  in 
conversation  persons  oppose  their  fixed  ideas,  and  generally  they  quietly,  though 
unwillingly  keep  silence  on  the  subject.  Should  actual  arguments  be  brought 
to  bear  against  them,  they  begin  to  scold  and  become  violent,  and  the  aggressor 
has  generally  lost  their  confidence  for  a  long  time.  To  some  of  these  patients 
their  former  true  personality  appears  dead ;  they  speak  of  it  as  ot  a  third  person,  and 
often  only  vague  recollections  of  it  penetrate  the  obscurity  in  which  the  old  ego 
is  involved. 

From  the  foregoing,  it  will  be  seen  how  very  numerous  the  intellectual  dis- 
orders are  in  those  patients,  or  rather  how  various  are  the  states  consequent 
upon  maniacal  and  rriclancholic  conditions,  and  comprehended  under  the  name 
of  chronic  mania.     New  investigations  may  throw  further  light  on  this  subject. 

The  following  examples  will  still  further  aid  in  giving  a  correct  idea  of  this 
form. 

§  150.  Hallucinations  and  illusions  of  all  the  organs  of  sense  are  in 
no  form  of  insanity  so  frequent  as  in  chronic  mania,  and  in  many  cases, 
they  nourish  and  maintain  the  delirium.  Frequently  the  pati-ent  con- 
verses or  quarrels  continually  with  the  voices  which  he  hears,  and  falls 
into  angry  excitement;  frequently  he  finds  his  whole  happiness  in  a 
pleasing  illusion  of  sight,  like  the  demented  mother  whose  darling  long- 
lost  child  was  represented  to  her  by  a  broken  jug  clothed  with  rags, 
which  she  for  many  years  cherished  with  the  greatest  tenderness. 

The  movements,  the  appearance,  and  the  conduct  of  these  patients 
always  manifest,  even  in  the  mildest  forms,  a  certain  perversity  and  dis- 


STATES    OF    MENTAL    WEAKNESS.  233 

tortion.  The  physiognomy  generally  appears  old  and  withered,  and  has 
an  expression  of  stupidity  or  of  the  dominant  delirious  idea.  Nearly  all 
manifest  certain  peculiarities  in  their  conduct :  some  gesticulate  constantly, 
or  move  their  hands  and  feet  in  a  monotonous  manner;  others  jireserve 
an  ecstatic  stillness,  in  order  to  listen  to  their  hallucinations;  others  walk 
up  and  down  incessantly  in  a  favorite  place,  like  animals  in  a  cage,  and 
speak  or  hum  words,  rhymes,  or  melodies.  Some  always  remain  in  the 
darkest  corners  they  can  find,  turn  their  back  to  the  passer-by  and  are 
irritated  by  every  disturbance;  others  constantly  employ  themselves  in 
collecting  trifles  of  every  description — rags,  pebbles,  shells,  etc. — to  which 
they  attribute  great  value;  while  others,  again,  decorate  themselves  fan- 
tastically with  everything  they  can  lay  their  hands  on. 

Generally,  with  the.  cessation  of  the  melancholic  or  maniacal  state 
there  occurs  a  marked  increase  in  the  size  of  the  body  and  a  state  of 
robust  physical  health.  Every  asylum  contains  patients  who  live  for 
many  years  in  moderate  health  and  attain  a  great  age. 

Intermissions  or  remissions  never  occur  in  these  states,  and  all  experi- 
ence goes  to  show  that  complete  recovery  is  impossible;  but  by  the  com- 
munications of  Leuret  it  is  placed  beyond  doubt  that,  by  energetic 
methodical  treatment,  some  of  these  patients  can  be  made  "to  suppress 
their  delirium  and  lay  aside  their  peculiar  habits  to  such  a  degree  that  they 
may  be  rendered  capable,  to  a  considerable  extent,  of  pursuing  simple 
avocations.  If  these  patients  be  left  to  themselves,  they  become  more 
and  more  engrossed  in  their  delirious  conceptions;  these  gradually  extend 
to  wider  ranges  of  thought,  and  the  patients  finally  fall  into  complete  or 
apathetic  dementia. 

Example  XLIII. — Chronic  mania  and  inonomania. — In  1824  there  was  a 
young  man  in  the  lunatic  wards  of  the  Charite  at  Berlin  who  had  been  there  for 
about  eight  years.  He  was  more  the  object  of  attention  and  care  than  of  medical 
treatment;  he  walked  about  the  corridors  and  in  the  rooms,  appearing  to  take  an 
interest  in  all  that  went  on  around  him,  but,  to  speak  truly,  occupying  himself 
with  nothing.  He  laughed  and  mocked  at  everything  with  great  haughtiness; 
and  if  any  one  happened  to  ask  him  auytliing,  he  replied  with  great  assurance, 
and  with  a  perfectly  self-satisfied  air,  because — and  there  lay  the  foundation  of 
his  insuperable  egotism — he  was  all,  knew  all,  possessed  all,  and  could  do  all.  No 
station  was  higher  than  his,  no  knowledge  equalled  his;  his  fortune  was  as  great 
as  his  knowledge,  and  proportioned  to  the  station  which  he  believed  himself  to 
occupy.  This  assurance  which  he  had  of  his  greatness,  his  cleverness,  and  his 
l^ower  came  out  in  all  his  acts  and  movements.  A  consummate  actor  would 
have  had  difficulty  in  expressing  the  magnificence  and  disdain  manifested  by  this 
young  man,  simply  clad  in  a  blouse  and  seated  on  a  wooden  box.  The  fact  is, 
that  never  had  man  profounder  conviction  of  his  own  merits  and  greatness. 
According  to  information  given,  this  unhappy  young  man,  after  an  examination 
for  which  he  had  worked  hard,  and  in  which  he  had  failed,  became  silent,  sad, 
and  fell  at  length  into  the  state  wherein  we  find  him.  In  reality,  it  is  often  in 
this  way  we  see  fixed  ideas  appearing.  The  same  thing  is  observable  in  the  case 
of  those  who,  by  unhappy  speculations,  have  fallen  into  the  profoundest  misery, 
and  who,  exhausted  by  intellectual  work,  can  no  longer  engage  in  them;  their 
intelligence  is  disturbed,  and  suddenly  they  present  themselves  to  their  friends 
destitute  and  speaking  of  their  wealth. 

By  the  side  of  this  invalid  whose  portrait  I  have  rapidly  sketched,  and  who 
was  well  known  to  me,  I  have  set  another,  lately  come  to  the  asylum,  and 
respecting  whom  I  shall  say  the  little  I  know  of  him. 

M.  S— ,  aged  about  30,  in  a  good  position  in  business  which  brought  him  in  a 
great  deal,  of  agreeable  temper,  but  easily  excited,  addicted  during  several  years 
to  an  irregular  life,  distracted  by  pleasures,  often  excited  and  enfeebled  by  al- 
coholic liquors,  became  demented.  A  long  and  uninterrupted  series  of  pleasure 
of  every  kind  seems  to  have  induced  the  explosion  of  an  old  tendency  to  madness. 
To  every  question  addressed  to  him  he  replied,  "  I  am  a  colonel,  adjutant-general; 


234  STATES    OF    MENTAL    WEAKNESS. 

I  am  a  capital  player  at  billiards,  an  extraordinarily  expert  lioreeman;  lately,  I  got 
on  horseback  in  the  circus,  and  I  distanced  all  others  by  the  skill,  strength,  art, 
and  marvellous  elegance  with  which  I  managed  the  most  restive  horses.  I  am 
very  rich;  I  invite  you  to  come  to  iny  house — I  want  to  have  a  little  amusement. 
The  man  you  have  given  me  here,  and  whom  you  call  a  keeper,  pleases  me;  he 
also  saw  me  get  on  horseback  in  the  circus,"  etc.  I  answered  him,  "  To-morrow 
I  will  introduce  you  to  a  man  who  is  here,  who  will  certainly  take  an  interest  in 
you,  and  who  may  be  useful  to  you."  M.  S —  then  said  to  me  very  quietly,  "  I 
shall  be  very  glad;  I  like  to  have  a  great  many  friends,  and  I  like,  too,  to  be  on 
good  terms  with  everybody." 

M.  H — was  standing  in  the  corridor,  supported  on  his  wooden  box,  with  a  look 
of  self-satisfaction,  when  I  brought  M.  S —  to  him,  saying,  "  Here  Is  a  gentleman 
whose  acquaintance  will  perhaps  interest  you."  M.  H —  approached  M.  S — ,  fixed 
his  eyes  on  him,  and  having  watched  him  some  moments,  threw  his  head  back- 
w^ard,  saying,  "Who  are  you?"  M.  S — :  "I  am  a  colonel  of  His  Imperial 
Majesty  of  Russia,  and  adjutant-general."  M.  H — :  "  It  is  not  unpleasant  for  me 
to  make  your  acquaintance.  I  shall  take  a  great  interest  in  you  out  of  regard  to 
your  position,  and  you  may  be  quite  sure  of  my  patronage,  for  I  am  a  field- 
marshal,  and  during  my  leisure  hours  I  occupy  myself  with  the  organization  of 
the  naval  and  military  forces  of  Russia."  M.  S — ,  astonished  at  the  unheard  of 
arrogance  of  his  interlocutor,  looked  about  him  quite  embarrassed,  while  M.  H — 
looked  at  him  with  all  possible  dignity  of  manner,  and,  tilled  with  the  conscious- 
ness of  his  vast  superiority,  he  said  to  liim,  "  Have  you  still  some  other  accom- 
plishments which  I  might  put  to  use?"  '"Yes,  Mr.  Marshal,"  replied  M.  S — , 
approaching  M.  H — with  a  kind  of  familiarity;  "  I  am  chief  of  the  outriders;  I 
am  a  horseman  of  great  strength  and  an  admirable  .  .  ."  Then  M.  H — ,  throw- 
ing himself  back  and  assuming  a  still  grander  air,  while  he  shot  at  him  as 

disdainful  a  look  as  possible,  "  Vile  hateleur,"''  said  he,  "  miserable ,  worthy 

of  being  in  a  madhouse! "  and  he  withdrew  haughtily.  He  assumed  his  ordinary 
position  beside  the  wooden  box,  with  a  crushing  look  at  M.  S — ,  who  was  greatly 
frightened.  I  then  led  away  M.  S — ,  saying  to  him  iu  a  low  voice,  "  How  could 
you  say  such  things  to  this  gentleman?"  M.  S — replied,  "I  never  did  get  on 
horseback,  as  I  said  just  now,  but  I  often  thought  how  good  it  would  be  to  be 
able  to  do  it.  I  wish  I  could  tell  this  gentleman  that  I  did  not  get  on  liorseback 
with  the  groom  of  the  circus.  Take  me,  I  pray  you,  immediately  to  him."  I  re- 
plied, "  You  have  got  yourself  into  a  terrible  scrape  with  him.  As  you  know 
quite  well,  you  placed  yourself  in  a  bad  position  by  saying  such  things.  Don't 
try  it  again,  for  you  see  the  contempt  which  that  ill-advised  banter  has  brought 
upon  you."  M.  S — :  "But  I  am  colonel  and  adjutant-general  all  the  same." 
"  That  is  another  matter,"  I  replied,  "  and  we  shall  talk  about  it  afterwards;  but, 
at  present,  you  have  forever  forfeited  the  esteem  of  that  man.  Take  care  that 
the  same  thing  does  not  happen  in  the  case  of  other  people."  The  keeper  walked 
with  M.  S — ,  and  told  me  afterwards  that  he  had  continued  to  talk  with  him  of 
that  affair.  He  said  to  me,  that  from  that  moment  M.  S —  ceased  to  believe 
himself  a  groom,  but  he  still  believed  himself  to  be  a  colonel.  The  patient,  who 
was  in  that  condition  during  the  last  four  months,  was  quite  cured  in  the  course 
of  several  months  which  followed  that  meeting  in  which  M.  H —  had  so  rudely 
shaken  his  insane  notions,  which  were  henceforth  arrested  in  their  further  devel- 
opment. M.  H —  always  shunned  hun,  never  spoke  to  him,  and  treated  him  with 
profound  contempt.  M.  S —  was  always  ashamed  in  his  presence,  as  if  he 
remembered  the  disdain  which  M.  H^  had  manifested  towards  him  at  their  first 
interview.  It  was  only  when  quite  cured  that  he  got  rid  of  the  embarrassment 
w^hich  he  experienced  in  presence  of  M.  H — .  When  he  was  completely  ciu'ed, 
and  was  about  to  quit  the  asylum,  M.  S —  extended  his  hand  to  M.  H — ,  for  whom, 
since  his  restoration,  he  showed  a  real  attachment;  but  he  received  him  with  the 
same  contempt  as  formerly,  more  than  ever  persuaded  of  his  influence,  of  his 
fortune,  and  of  the  immense  distance  which  separated  them.  M.  H —  remained 
in  tlie  asylum — he  was  incurable;  M.  S — ,  on  the  contrary,  owed  his  recovery, 
doubtless,  to  the  meeting  which  he  had  with  him  after  his  arrival  in  the  hospital. 
(Sinogowitz,  '  Die  Geistesstorungen,'  etc.,  1843,  p.  22.) 

Example  XLIV. — Chronic  mania  of  many  years''  standing;  habits  capricious, 
but  intimately  connected  with  the  leading  delusion. — The  w^oman  13 —  was,  wlien 
she  came  under  my  observation,  about  05  years  of  age.  So  far  as  known,  she  had 
been  an  inmate  of  asylums  since  slie  was  sixteen.  In  her  deiiortment  she  con- 
stantly showed  traces  of  superior  training.     I  could  never  learn  whether  she  had 


STATES    OF    MKNTAL    WEAKNESS.  235 

any  relations  still  living;  nobody  visited  her,  and  I  had  no  other  means  of  infor- 
mation.    Her  once  fair  and  luxuriant  hair  was  now  nearly  gray;  her  forehead 
wrinkled,  her  deeply -set  blue  eyes  were  very  movable,  and  when  excited  they  act- 
ually sparkled;  her  gait  was  generally  slow,  and  she  moved  without  definite  direc- 
tion— always  as  if  looking  for  something,  and  in  semicircles.     She  never  greeted 
anyone,  nor  acknowledged  a  salutation;  it  was  only  rarely  that  slie,  when  saluted 
by  any  one  not  known  to  her,  would  look  up,  minutely  examine  the  individual, 
then  rapidly  withdraw  her  eyes  and  occasionally  murmur  a  few  incomprehensible 
words.     At  other  times  she  replied  to  all  communications  which  were  addressed 
to  her  with  several  severe  words  of  reproach,  which  generally  concluded  by  her 
withdrawing  from  all  further  communication,  and  pronouncing  this  judgment: 
"  He  shall  be  burned.''    If  listened  to,  there  would  ensue  a  violent  scene  highly 
disturbing  to  those  around  her.     Therefore,  the  old  incurable  patient  was  left  to 
herself,  and  no  attention  paid  to  her  harmless  energy.     When  let  alone,  she 
offended  no  one,  carefully  avoided  all  contact,  seemed  occupied  only  with  very 
urgent  affairs,  and  froni  long  custom  joined  in  the  ordinary  household  arrange- 
ments.    She  often  wrote  letters,  which  consisted  entirely  of  capital  letters;  they 
were  always  written  on  large  sheets  of  paper,  and  addressed  to  the  most  powerful 
monarchs  in  the  world  and  their  wives.     She  always  accepted  a  few  sheets  of 
large  paper  and  some  pens  with  marks  of  gi-atitude,  although  she  never  expressed 
her  thanks,  and  generally  rapidly  disappeared  from  the  donor.     From  a  number 
of  her  letters,  I  gathered,  not  without  some  trouble,  the  following  regarding  her 
ideas: — The  old  woman  believed  herself  to  be  a  queen,  daughter  of  the  sun,  and 
near  relative  and  friend  of  all  monarchs.     She  hoped  to  be  drawn  in  a  coach  of 
gold,  drawn  by  six  horses.     Most  of  the  letters  were  directed  to  the  ruler  of  the 
Sublime  Porte  and  his  wife.     The  letters  to  the  monarchs,  which  she  wrote  almost 
regularly  three  or  four  times  a  year  (she  also  wrote  to  the  judges  of  the  earth 
and  to  the  general  executioner  of  the  world),  generally  contained  requests  and 
special  demands  that  those  persons  might  be  burned  who  had  on  several  occasions, 
and  perhaps  intentionally,  disturbed  her  in  her  employments.     If  the  name  and 
designation  of  such  persons  were  vinknown  to  her,  she  would  give  a  description 
of  them,  according  to  their  clothing  and  habits,  so  true  that  the  persons  meant 
could  be  easily  recognized,  in  order  that  the  high  monarchs  might  commit  no 
mistake.     If  any  one  were  doomed  by  her  to  be  burned  in  one  of  these  letters, 
she  repeated  to  him  his  judgment  each  time  she  saw  or  spoke  to  liim:  pardon 
need  no  more  be  expected.     This  patient  was,  as  already  mentioned,  an  accu- 
mulator of  uncommon  perseverance.     Only  on   very  cold  and  rainy  days  did 
she  desist  from  collecting,  but  wlien  the  sun  shone  during  the  hours  of  recreation 
in  the  garden  she  was  most  active.     Quite  absorbed  in  her  work,  she  collected 
small  colored  stones,  dead  brilliant  beetles,  flies,  certain  small  leaves,  twigs, 
colored  feathers,  rags,  bright  pieces  of  glass,  etc.     If  she  had  made  a  large  collec- 
tion, when  the  recreation  hour  ended  she  cast  radiant  glances  towards  her  pocket, 
and  rapidly  sought  her  room  in  order  to  conceal  her  treasure.     With  a  certain 
cunning,  and  even  with  open  resistance  if  hindered,  she  would  attempt  to  with- 
draw herself  from  the  next  walking  party,  in  order  that  she  might,  when  possible, 
be  alone  in  her  room.     In  this  solitude  I  found  opportunity  to  observe  her  un- 
noticed, and  cannot  speak  without  emotion  of  what  I  saw.    She  opened  a  window 
on  the  sunny  side  of  the  apartment,  and  looked  a  few  moments  at  the  sun;  then 
she  drew  from  all  her  pockets  and  from  the  places  of  their  concealment  her 
treasures,  spread  them  before  her  on  the  window,  and  viewed  them  for  a  tune,  in 
profound  contemplation;  she  then  tied  these  gaudy  articles,  fastened  with  green, 
yellow,  red,  and  white  threads,  between  the  iron  bars  outside  the  window,  so  that 
they  remained  suspended  in  rows.  When  this  bright  array  was  finished,  sheopened 
the  door  opposite  the  window,  which  caused  a  draught.     When,  owing  to  this, 
the  slightly  fastened  leaves,  feathers,  rags,  etc.,  commenced  to  flutter,  the  old 
woman  would  look  with  joy  expressed  in  her  eyes  alternately  at  them  and  at  the 
sun,  and  weep  for  joy;  she  noiselessly  moved  backwards  and  forwards  like  to  a 
child  delighted  with  its  toys.     As  the  time  advanced,  she  would  hear  the  noise  of 
the  approach  of  her  neighbors  from  the  garden,  and  rapidly  and  carefully,  dis- 
turbing nothing,  pack  up  all;  and  when  those  who  shared  her  apartment  entered, 
no  trace  of  them  would  be  observed.    As  I,  during  my  repeated  observations,  ap- 
proached (she  was  so  engrossed  that  she  did  not  observe  my  approach)  and  quietly 
stood  beside  her,  she  bore  my  presence  without  scolding,  and.  observed  me  with 
joy  expressed  in  her  eyes.     Quietly  I  withdrew,  and  was  afterwards  several 
times  enabled  to  witness  the  same  scene,  although  I  had  already  been  doomed  to 
be  bui'ned  in  her  letters. 


236  STATES    OF    MENTAL    WEAKNESS. 

I  directed  that  tliis  unfortunate  woman  should  not  be  annoyed  during  her 
hours  of  recreation;  for  no  one  has  a  right,  without  some  good  motive,  to  break 
upon  the  happiness  of  his  neighbor.  Accordingly,  this  old  woman  enjoyed  in 
peace  her  small  measure  of  happiness  until  her  death,  wliich  occurred  a  few  years 
aftei'wards.  She  was  more  than  fifty  years  in  asylums;  her  insanity  had  never 
been  cui'ed,  but  had  often  been  aggravated  by  her  quarrelsome  neighbors. — 
(Siuogowitz,  '  Die  Geistesstorungen,'  Berl.,  1843,  p.  35.) 

Example  XLV. — Chronic  mania  tvith  the  character  of  depression;  hallucina- 
tions of  hearing. — One  day  I  was  accosted  at  the  Salpetriere  by  a  woman  I  had 
never  before  seen.  She  had  a  quiet  and  timid  air;  she  looked  at  me  as  if  trem- 
bling, and  did  not  speak.  Her  dress  was  simple  and  decent.  I  judged  her  about 
forty  years  of  age,  and  afterwards  discovered  that  this  was  indeed  her  age.  I  stood 
stiU  near  her,  and  she  continued  to  look  at  me.  Speedily  I  saw  her  face  assume 
an  expression  successively  of  anxiety  and  terror;  then  she  remained  calm,  and  I 
would  have  said  that  she  was  listening,  and  soon  again  the  movements  of  her 
features  indicated  agitation  of  mind.  I  walked  a  hundred  paces  witout  saying  a 
word,  and  without  appearing  to  fix  my  attention  on  her.  She  followed  me,  and 
continued  her  quiet  action.  I  stopped  again,  and  regarded  her  attentively,  with- 
out seeming  to  be  the  least  curious.  She  did  not  discontinue  her  quiet  conversa- 
tion, for  I  saw  that  she  talked  with  me;  and  although  my  impassibility  was  as 
great  as  possible,  she  heard  objections  and  reproaches  to  which  she  hastened  to 
respond.  We  continue  looking  at  each  other  in  this  way  for  nearly  half  an  hour, 
when  she  murmured  some  words  which  I  did  not  comprehend.  I  gave  her  my 
note-book,  on  which  she  wrote  as  follows:  "  Clemence,  brought  to  the  Salpetriere, 
ignorant  of  all  that  has  passed  here,  for  I  have  not  deserved  such  a  punishment 
for  having  merited  so  little  happiness.  I  swear  that  I  have  not  stolen  from  any 
one;  that  I  have  not  borrowed  from  any  one  all  that  is  in  my  room — the  jewels, 
the  goblets  of  silver;  that  I  am  come  with  confidence;  that  I  have  never  engaged 
in  the  lottery;  that  I  will  go  everywhere  with  honor;  that  I  saw  the  mill 
turn.  .  .  ." 

Then  she  gave  me  back  my  note-book,  and  continued  as  before.  At  length 
she  said,  "  But,  sir,  why  do  you  not  speak  out  to  me?  I  do  not  know — nothing 
at  all,  sir — when  nothing  is  said.  ,  .  .  Never  have  I  been  in  a  bad  place.  I  do 
not  know  what  it  is  you  would  say  to  me.  If  any  one  has  sent  me  to  sleep  by  a 
drug,  I  don't  know  what  has  passed.  No  !  sir,  I  have  never  been  unfaithful  to 
him.     If  monsiem*  want  to  answer  me  ?  " 

"What  diff'erence  do  you  find  in  my  answers,  according  as  I  move  my  lips  and 
as  I  don't  move  them  ?  " 

"  I  find  that  you  express  yourself  frankly,  and  I  prefer  to  hear  you  speak.  I 
hear  your  thought,  and  I  don't  know  why.  .  .  .  No,  sir,  I  never  dipped  my  hands 
in  blood  ;  never  did  I  assassinate.     Yes,  sir,  I  love  him  still." 

"  How  does  it  happen  that  you  heard  my  thoughts  ?" 

"I  think  that  it  is  by  physic  that  I  heard  him  s^jeak.  .  .  .  Even  when  there  is 
nobody,  I  hear  talking." 

'  •  Are  sad  things  ever  said  to  you  ?  " 

"  I  never  hear  agreeable  things.  .  .  .  You  will  see  if  my  conduct  will  not 
always  be  the  same.'' 

"  When  were  you  married  ?  " 

"  I  could  not  tell  j'ou  exactly," 

"Do  you  remember  what  day,  what  month;  whether  it  was  in  winter  or 
in  summer  ?  " 

"No,  sir,  I  have  forgotten,  by  the  work  which  has  been  laid  on  me,  by  the 
baths  and  fasting.  I  believe  I  am  pregnant  ;  I  have,  perhaps,  serpents,  but  my 
husband  is  not  a  serpent.  I  felt  myself  carried  off.  The  King  of  France  ^s  come  ; 
I  made  a  crown,  and  I  said,  'If  l' have  deserved  a  crown  of  thorns,  I  am  quite 
willing  to  wear  it.'  I  don't  know  how  I  came  back  to  earth,  and  it  appears  as  if 
underneath  me  everything  was  engulfed.'"— (Sinogowitz,  '  Die  Geistesstorungen,' 
Berhn,  1843,  p.  35.) 

Example  XLVI, — Clironic  mania;  loss  of  personal  identity;  hallucinations 
of  all  the  senses. — An  invalid,  of  the  division  of  Pariset,  aet,  56,  eujoymg,  to  all 
appearance,  good  health,  has  lost,  since  183T,  the  consciousness  of  her  personality, 
and  believes  herself  to  be  quite  another  woman  tliun  she  was  formerly.  That 
belief  seems  to  be  united  to  a  change  which  has  taken  place  in  her  way  of  feel- 
ing, and  especially  to  hallucinations,  various,  and  manifold,  and  continual.  She 
never  speaks  of  herself  except  in  the  third  person,  and  employing  this  phrase — 
' '  the  person  of  me. " 


STATES    OF    MENTAL    WEAKNESS.  237 

Provided  one  does  not  come  too  near  her,  and  does  not  touch  her  bed,  her 
chair,  or  her  garments,  nor  anytliing  that  belongs  to  her,  one  succeeds  easily  in 
conversing  with  her.     She  replies  kindly  and  politely,  "  How  are  you,  madam?" 

"  The  person  of  me  is  not  a  dame  ;  call  me  miss,  if  you  please." 

"  I  don't  know  your  name  ;  be  kind  enough  to  tell  me." 

"  The  person  of  me  has  not  a  name  ;  she  desires  you  not  to  write  it." 

"  I  would  like  much  to  know  your  name,  or  rather  what  you  were  once 
called." 

' '  I  understand  what  you  mean.  It  was  Catherine  X.  We  mustn't  talk  further 
of  wliat  took  place.  The  person  of  me  has  lost  her  name  ;  she  gave  it  up  on  enter- 
ing the  Salpetriere." 

"  What  is  your  age  ?  " 

"  The  person  of  me  has  no  age." 

' '  But  that  Catherine  X.  of  what  of  whom  you  spoke,  how  old  was  she  ?  " 

"  I  don't  know.    She  was  born  in  1779,  of  Mary  and  James ,  living  at , 

and  was  captured  at  Paris,  etc." 

"  If  you  are  not  the  person  of  whom  you  speak,  you  are  perhaps  two  persons 
in  one?'' 

"  No  !  the  person  of  me  does  not  know  that  which  was  born  in  1779.  It  is, 
perhaps,  that  lady  you  saw  down-stairs." 

"  Ai'e  your  parents  still  alive  ?  " 

"  The  person  of  me  is  alone,  and  much  alone  :  she  has  no  relations,  and  never 
had  any." 

"  And  th^  relations  of  the  person  whom  you  formerly  named  ?  " 

"  Folks  say  they  are  still  alive  ;  they  call  themselves  my  father  and  my  mother, 
and  I  believed  it  up  to  the  year  1827.  I  fulfilled  my  duty  to  them  up  to  that 
period  " 

"  You  are  therefore  their  child  ?  Your  mode  of  speech  shows  that  you  think 
so." 

"The  person  of  me  is  no  one's  child.  The  origin  of  the  person  of  me  is 
unknown  ;  she  has  no  recollection  of  the  past.  The  woman  of  whom  you  speak 
is,  perhaps,  she  for  whom  this  dress  has  been  made  (pointing  to  her  dress) ;  she 
was  married,  and  had  several  children."  (Minutely  relates  the  circumstances  of 
her  former  life,  but  always  stops  at  the  year  1827.) 

"  What  have  you  done,  and  what  has  happened  to  you  since  you  became  that 
person  ?  " 

' '  The  person  of  me  lives  in  the  asylum  at .     They  make,  and  still  make 

physical  and  metaphysical  experiments  with  her.  This  work  was  unknown  to 
her  before  1827. — Here  comes  a  spirit,  and  mixes  its  voice  with  mine.  The  person 
of  me  will  not  have  this,  and  sends  it  quietly  back." 

' '  What  like  are  the  spirits  of  whom  you  speak  ?  " 

"  They  are  small,  and  cannot  be  laid  hold  of." 

"How  are  they  clad ? " 

"In  blouses." 

"  What  language  do  they  speak?" 

' '  French.  If  they  spoke  in  any  other  language,  the  person  of  me  could  not 
iinderstand  them.' 

"Is  it  actually  certain  that  you  see  them?" 

"Quite  certain;  the  person  of  me  sees  them,  but  metaphysically,  in  invisi- 
bility, not  materially;  else  they  would  not  be  invisible." 

"  Do  you  sometimes  experience  odors?" 

"  A  feminine  composition,  invisible,  has  sent  bad  odors  to  me." 

"  Do  you  sometimes  feel  the  invisible  in  your  body  r" 

"  The  person  of  me  feels  it,  and  is  very  angry  at  it  ;  it  has  perpetrated  all  sorts 
of  immodest  deeds  upon  her." 

"Have  you  a  good  appetite?" 

"  The  person  of  me  eats  ,  she  has  bread  and  water.  The  bread  is  as  good  as 
any  one  could  wish  ;  she  desires  nothing  more,"  etc. 

"  Do  you  pray  sometimes  ?" 

"  The  person  of  me  knew  her  religion  previous  to  1827  ;  she  knows  it  no  more." 

"  What  do  you  think  of  the  women  who  live  with  you  in  this  room  ?  " 

"  The  person  of  me  thinks  that  they  have  lost  their  judgment;  at  all  events, 
the  most  of  them." — (Leuret,  '  Fragments  Psychol.,'  p.  121.) 

Example  XLVII. — Chronic  viania  unth  the  character  of  exaltation. — A  woman 
at  present  in  the  Salpetriere  believed  herself  to  be  at  the  same  time,  God,  Jesus 


238  STATES    OF    MENTAL    WEAKNESS. 

Christ,  and  the  Holy  Virgin.  Adorned  with  ribbons,  with  a  bunch  of  feathers 
and  paper  flowers  upon  her  head,  she  joyfully  roamed  about  the  grounds  of  the 
hospital.  She  had  told  me  who  her  parents  were,  and  related  circumstances 
which  she  had  witnessed  in  her  early  years.  We  had  the  following  conversation 
together: — 

'*' When  did  you  become  God?" 

' '  Three  years  after  my  marriage ;  one  day  I  wanted  to  jump  out  at  the  window,  , 
but  I  felt  something  restraining  me." 

' '  From  whom  ?  " 

"  From  God." 

"  You  are  God;  it  was  therefore  yourself  who  restrained  you?" 

"  Yes.  and  on  another  day  I  went  to  confession." 

"  Then  you  had  not  yet  become  God?" 

"  No,  I  did  not  then  feel  that  I  was." 

"  Jesus  Christ  was  a  man,  and  you  are  a  woman.  You  cannot  therefore  be 
Jesus  Christ?" 

"  Ah  !  my  dear  sir,  that  is  a  mystery— I  know  nothing  of  that;  I  am  the  Virgin 
Mary." 

"  It  seems  to  me  that  you  have  no  cause  to  consider  yourself  God  ?  " 

"  I  will  punish  all  those  who  thvis  offend  me;  God  cannot  descend  from  his 
throne  to  avenge  me." 

"  Do  not  excite  yourself;  you  are  God,  are  you  not  ?  " 

"Yes." 

"  Are  you  here  of  your  own  accord  ?  " 

"  No;  I  was  on  a  pilgrimage,  when  I  was  waylaid,  and  brought  into  this  hos- 
pital." 

"  Why,  then,  did  you  allow  it,  if  you  were  God?  " 

"  I  could  not  prevent  it;  it  is  not  for  me  to  go  against  the  authorities.  The 
state  procurator  would  not  let  me  go.  We  shall  have  a  great  war,  a  civil  war.  I 
have  written  to  Louis  Philippe,  saying  that  he  will  be  king  for  two  years  yet.  I 
have  a  brother  who  has  four  sons,  and  they  are  apprentice  kings."— <Leuret, 
'  Fragments  Psychologiques,'  1834,  p.  323.) 

Example  XLYIII.— Systematically  developed  and  dramatized  delusions  of 
bodily  and  mental  influences.  Hallucination  of  all  the  senses,  especially  of  the 
cutaneous  sensibility;  possibility  of  completely  concealing  the  delusion.— B.As\a.m 
narrates,  in  his  small  work,  '  Illustrations  of  Madness,'  London,  1810.  the  history 
of  a  man,  named  Matthews,  who,  in  the  year  1797,  in  consequence  of  a  judicial 
verdict,  was  received  into  the  hospital  of  Bethlehem;  in  1798  he  was  removed  to 
the  division  for  incurables.  There  he  remained  for  several  years,  sometimes  con- 
sidering himself  the  subject  of  experiments  made  by  certain  persons— sometimes 
the  emperor  of  the  world.  In  1809,  his  relatives,  who  were  opposed  to  his  residence 
in  Bethlehem,  proposed  that  he  should  be  dismissed,  and  requested  Drs.  Clutter- 
buck  and  Birkett  to  inquire  more  minutely  into  his  mental  condition.  These 
gentlemen,  after  having  visited  the  patient  four  times,  certified  on  soul  and  con- 
science that  Matthews  was  in  a  state  of  perfect  mental  health.  A  new  commission 
of  eight  physicians  was  now  appointed,  who,  after  a  long  examination,  granted  a 
certificate,  also  on  oath,  that  the  man  teas  in  a  high  degree  insane. 

And  indeed  he  was.     He  cherished  the  delusion,  in  its  details  highly  elaborated 
and  dramatized,  that  a  band  of  wicked  men  acted  upon  him  m  a  great  many  tvays 
by  magnetic  currents  from  an  apartment  in  the  vicinity  of  the  town-wall.     He 
heard  and  saw  these  persons,  and  can  therefore  minutely  describe  them.     There 
are  seven  of  them,  four  men  and  three  women.     The  chief  amongst  them  is  one 
named  Bill,  also  called  the  King :  lie  is  from  sixty-four  to  sixty-five  years  ot  age; 
his  thoughts  are  constantly  directed  towards  wicked  objects;  no  one  ever  saw  liiin 
laugh.     The  second  is  called  Jack  the  Schoolmaster,  who  also  calls  himself  the 
Registrar,  about  sixty  years  old,  tall  and  thin.     The  third  person  is  Sir  Archy, 
aged  fifty-five:  wears  a  dirty-colored  coat  and  knee-breeches;  he  constantly  em- 
ploys sly  sarcastic  language,  and  speaks  with  a  provincial  accent.     The  fourth  is 
called  the  Middle-man:  is  fifty-seven  years  of  age;  has  a  hawk  like  expression, 
wears  a  blue  coat  and  a  glossy  vest,  and  constantly  sits  grinning.     The  first 
woman  is  called  Augusta:  thirty-six  years  old,  of  medium  height,  and  character- 
ized by  the  sharpness  of  her  features.     She  dresses  in  black,  like  a  country  sliop- 
keeper's  wife,  and  wears  her  hair  unpowdered.     The  second  is  called  Charlotte: 
she  is  a  ruddy  brunette,  and  very  like  a  French  woman.  The  third  woman  is  very 
peculiar:  she  appears  to  have  no  Christian  name,  but  the  others  call  her  the  Glove- 


STATES    OF    MKJSITAL    WEAKJSEhS.  285) 

woman,  because  she  always  wears  cotton  gloves,  and  indeed,  as  Sir  Archy  dryly 
remarks,  to  keep  people  from  seeing  tliat  she  lias  the  itch. 

The  influences  which  these  imaginary  individuals  exert  upon  the  patient,  by 
means  of  a  complicated  machine  which  he  can  minutely  describe,  are  of  a  very 
various  nature.  The  patient  describes  a  number  of  these  various  torments  (hallu- 
cinations) in  his  own  terms,  thus : 

Obstruction  of  the  fluids— a  knotting  together  of  the  fibres  of  the  root  of  the 
tongue,  whereby  speech  is  brought  to  a  standstill.  Cutting  off  of  the  soul  from 
the  feelings — an  expansion  of  the  magnetic  current  from  the  root  of  the  nose  to 
the  under  surface  of  the  brain,  as  if  a  veil  were  spread  over  it,  so  tliat  the  feelmgs 

of  tlie  heart  are  disconnected  from  the  operations  of  the  mind.     Dragon-flying 

as  boys  fly  a  paper  dragon,  so  these  rascals,  by  means  of  their  art,  cause  any  spe- 
cial idea  which  strikes  them  to  arise  in  the  mind,  which  then  moves  to  and  fro 
for  several  hours;  and  should  he  wish  to  get  rid  of  the  idea  thus  forced  upon  him. 
and  call  forth  some  other,  he  cannot  do  so;  he  must  devote  his  whole  attention  to 
their  idea.  He  is  also,  during  the  whole  time,  conscious  that  the  idea  is  foreign 
to  him,  and  urged  upon  him  from  without.  Being  bound  down— a.  fettering  of 
judgment  in  reviewing  one's  thoughts.  Bursting  of  bomb-shells— one  of  the  most 
frightful  modes  of  being  influenced.  The  vital  fluid  present  in  the  brain  and  in 
the  nerves,  the  vapor  which  rises  up  and  down  in  the  blood-vessels,  the  gas  in  the 
stomach  and  bowels,  are  in  the  highest  degree  rarefied  and  rendered  combustible, 
which  then  causes  a  very  painful  expansion  of  the  whole  body.  During  the  suf- 
ferings of  the  unfortunate  victim,  these  rascals  let  loose  a  powerful  charge  of  the 
galvanic  battery,  which  produces  a  fearful  shock  and  rends  the  whole  body. 
Fearful  cracking  is  felt  within  the  head,  and  it  is  really  wonderful  how  the  great 
shock  does  not  cause  immediate  death,  etc. ,  etc. 

During  sleep,  Matthews  is  tormented  by  dreams.  These  rascals  have  many 
variouskmdsof  curiously  formed  dolls:  when  they  have  looked  at  these  for  a 
certain  time  continuously,  they  can  throw  the  image  of  these  figures  into  his  soul 
during  sleep,  etc. 

The  stuff  which  these  individuals  use  in  their  experiments  is,  according  to 
Matthews,  of  a  very  complex  and  various  nature— the  seminal  fluid  of  men  and 
of  women;  the  emanations  of  copper  and  sulphur;  the  vapor  of  vitriol  and  aqua 
fortis,  of  nightshade  and  hellebore;  the  excrement  of  dogs,  human  gas,  croton  oil, 
vapor  of  arsenic,  etc.  [See  the  detailed  communications  of  the  patient,  and  his 
description  of  the  machine,  in  Nasse,  '  Zeitschrift  fur  Psychiatric,'  A,  1818,  i.j 

Many  cases  fonnd  described  in  original  MSS,  or  in  pamphlets,  some 
of  them  published  by  tlie  patients  themselves,  belong  to  tlie  same  cate- 
gory as  this  case:  for  example,  '  Cry  of  Distress  of  one  who  is  poisoned 
by  Magnetism,'  Stuttg.,  1853;  also  the  case  described  by  Kieser  as  "Melan- 
cholia daraonomania  occulta"  ('  Zeitschrift  fiir  Psychiatric,'  x.,  1853,  p. 
423),  of  externally  concealed  mental  disorder  of  forty  years'  duration, 
with  the  delusion  of  being  the  continual  object  of  demoniacal  experi- 
ments, and  with  dominant  hallucinations  of  hearing. — Anomalies  of 
sensation  in  tlie  most  varied  parts  of  the  body,  which  in  these  cases  are 
so  fantastically  elaborated,  occasionally  occur  in  the  state  of  health. 
These  conditions  are  in  general  far  too  little  studied;  they  are  generally 
thrown  into  the  general  class  of  hypochondriacs,  audi  think  I  shall ao-ain 
refer  to  them  elsewhere.  A  patient  of  this  kind,  in  my  practice,  lind 
about  fifty  years  of  age,  has  for  many  years  experienced,  almost  uninter- 
ruptedly, the  sensation  of  a  constant  "heaving  and  lifting"  in  his  whole 
body.  A  young  man,  twenty-one  years  of  age,  7vJiose  father  had  been 
insane,  has  a  sensation,  which  has  been  constantly  increasing  since  his 
fourteenth  year,  as  if  h^ad  and  face  were  covered  with  threads,  and  some 
one  was  continually  pulling  at  them,  always  preferring  the  head;  lanci- 
nating pains  in  the  knees  and  shin-bones,  etc.  These  patients  do  not 
think  of  ascribing  their  malady  to  others;  but  their  abnormal  sensations 
would,  should  mental  disease  set  in,  immediately  afford  rich  material  for 
such  imputations. 


240  STATES    OF    MENTAL    WEAKNESS. 

Section"  II. — Dementia. 

§  151.  Under  the  states  of  mental  weakness  without  the  striking 
predominance  of  a  single  delirious  idea,  we  comprehend  under  the  name 
of  dementia — as  distinguished  from  apathetic  dementia — those  in  which 
the  patients  still  manifest  a  certain  degree  of  external  vivacity  and  activ- 
ity in  conversation  as  well  as  in  conduct,  indicating  that  there  still  exists 
some  variety  and  activity  of  thought  and  effort.  Here,  also,  there  are 
very  many  varieties  in  the  manner  in  which  the  mental  weakness  is  mani- 
fested. Most  characteristic  are  the  numerous  cases  whicli  in  their  exter- 
nal symptoms  present  an  apparent  similarity  to  mania:  this  similarity, 
however,  can  only  be  external  and  superficial. 

In  all  these  cases  the  fundamental  disorder  consists  in  a  general  weak- 
ness of  the  mental  faculties.  In  the  sphere  of  the  emotions  this  is  mani- 
fested in  the  increasing  incapacity  of  the  patients  for  any  profound 
emotion,  with  irregular  change  of  quite  superficial  emotions  or  persistent, 
complete  indifference.  Hate  and  real  love  are  alike  impossible  to  these 
patients;  privations  are  little  if  at  all  felt  by  them,  and  they  cannot 
rejoice  at  agreeable  occurrences.  If  an  occasional  turbulent  ebullition 
should  also  occur,  it  is  neitiier  the  result  of  strong  thought,  nor  of  an 
energetic  act  of  emotion  or  will;  indifference  quickly  returns,  and  it  is 
this  indifference  which  shows  the  abnormal  state  of  the  emotional  reac- 
tions towards  the  external  world  (laughing  and  amusing  themselves  in 
the  midst  of  the  saddest  events,  etc.).  The  dominant  disposition  of 
mind  presents  endless  varieties.  Some  of  these  patients  constantly  mani- 
fest a  lively  disposition;  they  laugh,  dance,  sing,  and  show,  in  their 
gestures  and  conversation,  pride,  self-satisfaction,  and  the  most  perfect 
assurance  (Moria — see  §  139);  others,  on  the  contrary,  are  in  a  perpetual 
state  of  anxiety — they  shed  many  tears,  and  present  the  symptoms  of 
grief  and  care.  Others,  again,  have  a  tendency  to  do  mischievous  acts, 
to  take  pleasure  in  the  misfortunes  of  others.  But  these  dispositions  are 
neither  the  result  of  an  external  (as  in  health)  nor  of  an  internal  (as  in 
mania  or  melancholia)  motive;  they  are  quite  superficial,  alternate  with 
each  other  Avithout  any  cause,  and  are  expressed  in  a  manner  altogether 
foolish  and  childish.  With  the  complete  indifference  and  absence  of  all 
actual  desires  which  characterize  the  patients,  we  sometimes  see  mani- 
fested disorderly  mental  movements  and  aimless  extravagant  impulses 
whose  meaning  the  patient  himself  cannot  understand,  and  the  reaction 
of  the  will,  where  this  still  exists,  has  throughout  the  character  of  tran- 
sitoriness  and  inconstancy. 

§  153.  While  in  the  sphere  of  the  emotions  all  tends  to  wards  feebleness, 
impotency  and  atony,  the  same  tendency  is  also  observed  in  even  a  still 
higher  degree  in  the  sphere  of  perception:  this  is  in  accordance  with 
what  has  been  already  said  regarding  the  connection  between  emotional 
weakness  and  weakness  of  perception.  This  appears  chiefly  in  the  form 
of  loss  of  memory,  and  the  power  of  reproduction  of  the  ideas  is  chiefly 
affected  in  this  manner — that  more  recent  events,  things  that  occur 
during  the  dementia,  are  almost  immediately  forgotten,  while  not 
unfrequently  former  ideas  connected  Avitli  events  which  happened 
long  ago  are  more  easily  reproduced:  still,  many  of  these  patients  have 
utterly  forgotten  their  former  life,  and  even  their  own  name.  As  all  the 
operations  of  the  mind  proceed  entirely  without  energy,  no  durable 
impression  is  retained  of  what  is  presented  to  it:  besides,  these  patients 
have  also  lost  the  power  of  comparing  separate  ideas,  of  deducing  a  gen- 


STATES    OF    MENTAL    WEAKNESS.  241 

eral  fact  from  them,  of  judging  and  of  concluding,  and  all  thought  has 
degenerated  into  a  disconnected  mass  of  fleeting  images  and_  words.  It 
is  a  useless  and  sterile  activity  of  the  intelligence,  which  indulges_  in 
unequal,  isolated,  and  incomplete  ideas,  but  is  incapable  of  combining 
them  into  a  distinct  Judgment.  From  this  there  results,  on  the  one 
hand,  the  impossibility  of  all  abstraction,  and,  on  the  other,  an  external 
incoherence  in  the  associated  images  and  ideas  which  proceed  from  acci- 
dental impressions  of  sense,  or  according  to  the  merely  external  connec- 
tion of  accidental  similarities  (for  example,  similarly  sounding_  words). 
From  this,  too,  there  results  the  want  of  all  logical  form,  the  irregular 
change  of  disconnected  ideas,  the  unmeaning  parrot-like  repetition  of 
words  and  phrases  from  custom  and  according  to  accidental  similarity  of 
sound,  incoherent  and  senseless  replies.  We  often  think  that  in  such 
patients  an  attempt  at  memory,  at  judgment,  and  at  attention  may  be 
discovered,  which,  however,  falls  powerless  and  inefficacious;  again,  we 
may  observe  breaks  in  their  sentences  in  which  the  intermediate  parts 
which  should  connect  them  and  form  the  transition  to  new  ideas  are 
wanting,  and  we  may  often  receive  the  impression  that  these  pitiable 
creatures  themselves  were  tacitly  and  painfully  feeling  their  own  inabil- 
ity to  direct  themselves  aright  amidst  these  broken  remains  of  psychi- 
cal life. 

Special  fixed  ideas,  true  delirious  conceptions,  are  never  produced 
anew  in  dementia:  those  which  formerly  existed  become  with  the  increas- 
ing weakness  less  intense,  and  the  patient  can  as  little  implicitly  rely  on 
them  as  he  can  energetically  adhere  to  anything.  Still,  the  reproduction 
of  the  ideas  which  are  developed  during  the  period  of  maniacal  excite- 
ment often  continues  for  a  long  time,  and  we  again  frequently  find  the 
extravagances  of  monomania  in  the  senseless  repetition  of  great  numbers, 
in  immense  and  romantic  id^as  of  their  own  greatness  and  large  posses- 
sions (thousands  of  millions,  diamonds,  worlds,  etc.).  These,  however, 
have  all  become  to  the  patient  a  mere  play  of  words,  and  are  totally  void 
of  thought. 

§  153.  The  organs  of  sense  may  perform  their  functions  quite  nor- 
mally; the  patients  see,  hear,  etc.,  correctly;  but  the  elaboration  and 
transformation  of  the  sensorial  impressions  into  adequate  ideas  in  the 
brain  no  longer  proceeds  properly,  or — and,  indeed,  ordinarily — halluci- 
nations exist  Avhich,  along  with  the  ideas,  share  the  character  of  incohe- 
rence, want  of  method,  and  abruptness. 

The  muscular  movements  are  in  many  cases  restricted,  owing  to 
commencing  or  progressing  general  paralysis.  Where  this  is  not  the  case 
the  corporeal  movements  are  restless  and  unsteady,  yet  awkward  and  little 
varied,  and  the  attitude  is  often  clumsy  and  helpless.  Sometimes  the 
patients  constantly  run  to  and  fro  as  if  they  were  looking  for  something, 
or  they  rove  about  dancing,  hopping,  gesticulating  with  the  hands  and 
making  odd  automatic  movements.  Their  demeanor  and  movements 
are  either  altogether  inexpressive,  or  are  expressive  only  of  very  weak 
emotions;  and  here  also  are  presented  many  childish  and  capricious  habits, 
such  as  collecting  rubbish,  remaining  always  in  bed,  pleasure  in  toys,  and 
dressing  fantastically.  Sometimes  they  manifest  a  wayward  refusal  of 
food,  and  other  symptoms  of  childish  obstinacy;  more  frequently  we 
observe  the  love  of  eating — they  frequently  swallow  the  most  loathsome 
things.  Very  many  of  these  patients  who  have  been  long  confined  in 
the  asylum  are  addicted  to  onanism,  and  we  may  frequently  gather  from. 
16 


24:2  STATES    OF    MENTAL    WEAKNESS. 

their  conversation  indications  of  considerable  disorder  of  the  sexual 
functions — a  circumstance  which  ought  to  receive  immediate  and  further 
investigation. 

The  physiognomy  is  generally  old  and  stupid,  the  expression  vacant, 
and  the  countenance  obscured  by  neglect  and  dirt.  The  physical  health 
may  be  good,  or  the  most  various  chronic  or  acute  diseases  may  be  present; 
not  unfrequently  there  is  a  great  tendency  to  become  corpulent. 

Complete  intermissions  never  occur  during  the  course  of  dementia. 
Eemissions  occur  in  such  a  manner  that  quieter  and  somewhat  more_  ra- 
tional states  alternate  with  the  periods  of  greater  turbulence  and  agitation. 
The  course  of  these  states  is  always  progressive;  the  mental  weakness 
constantly  increases,  and  is  most  rapid  when  the  dementia  is  complicated 
with  general  paralysis:  otherwise  the  patient  may  remain  in  the  same 
state  for  periods  of  several  years.     Recovery  never  takes  place. 

Example  XLIX. — Transition  of  monomania  into  complete  dementia. — Julia 
had  but  one  idea,  and  that  was  a  most  extravagant  one.  She  thought  she  was  the 
Almighty.  She  indeed  spoke  also  of  other  things  ;  but  her  sayings  were  without 
definite  aim  or  connection,  and  she  had  almost  none  of  the  habits  of  ordinary 
life.  There  is  not  yet  complete  loss,  but  only  considerable  weakness  of  all  the 
mental  faculties,  as  may  be  learned  from  the  following  conversation  : 

"Madame,  what  is  your  name?" 

"I  am  called,  my  name.  You  owe  me  a  field.  I  am  indeed  the  Almighty. 
JVly  understanding  has  been  curtailed  in  order  to  make  an  apron  of  it." 

"  How  old  are  you  ? " 

"  I  am  fourteen  years  old  "  (she  was  at  least  thirty). 

"  How  many  are  forty-five  and  three  ?" 

"That  makes  forty-eight.  Now!  some  has  stolen  both  my  gold  and  my 
jew^els." 

"  Who  took  them  from  you  ?  " 

"Ask  your  own  thoughts  ;  I  am  not  the  cuirassier  woman — I  am  the  Al- 
mighty." 

"  Since  when  have  you  been  the  Almighty  ?  "    . 

"  Always,  always — I  have  always  been  the  Almighty." 

"  But  the  Almighty  has  a  beard,  and  you  have  none." 

"  I  beg  your  pardon,  here  it  is  "  (pointing  to  her  hair). 

This  patient  seldom  remarks  anything,  and  her  attention  is  never  continuous. 
She  has  little  remembrance  of  the  past,  and  very  little  of  the  present.  She  is 
only  capable  of  the  simplest  acts— making  her  bed,  putting  on  her  clothes,  eatmg 
her  food.  She  knows  the  name  of  nobody  about  her,  although  she  has  lived  with 
them  for  several  years.  In  a  moment  she  passes  from  laughing  to  quarrelling, 
etc.    (Leuret,  'Fragments  Psych,,'  Par.,  1834,  p.  34.) 

Section  III. — Apathetic  Dementia. 

§  154.  Sometimes,  as  a  mode  of  termination  of  the  forms  we  have 
just  been  considering,  sometimes  without  the  antecedent  occurrence  of  the 
more  noisy  and  agitated  forms  of  dementia,  there  occur  still  deeper  and 
more  complete  states  of  paralysis  of  the  psychical  functions,  in  the  most 
extreme  degrees  of  mental  decay. 

The  inability  to  comprehend  several  ideas  and  to  compare  them  al- 
ways increases,  and  instead  of  the  numerous  abrupt  disconnected  ideas  seen 
in  the  preceding  forms,  there  gradually  ensues  almost  a  total  absence  of 
images  and  thoughts.  The  sensorial  impressions  are  no  longer  elabo- 
rated, nothing  comes  out  of  them;  memory  is  so  completely  effaced,  that 
not  merely  what  happens  in  one  moment  is  forgotten  in  the  next,  but  all 
reminiscences  of  bygone  times  are  almost  entirely  lost.  Language  even 
is  to  a  great  extent  forgotten,  so  that  the  patients  even  in  the  most  fav- 
orable cases  can  employ  only  a  few  current,  very  limited,  and  little  applic- 
able expressions;  more  frequently  the  few  words  that  remain  are  only  au- 


STATES    OF    MENTAL    WEAKNESS.  243 

tomatically  repeated,  or  tlie  words  tliemselves  are  not  entire,  but  are 
merely  ejaculations  of  accustomed  sounds.  This  very  high  degree  of  dnl- 
ness  of  the  imagination  and  loss  of  the  intelligence  is  accompanied 
by  extreme  weakness  of  the  will.  The  patient  can  no  longer  actuate 
himself  to  do  anything,  even  by  the  force  of  former  habits;  he  must  ra- 
ther passively  submit  to  be  directed  by  some  extraneous  impulse.  He  is 
frequently  unable  to  supply  his  simplest  wants,  and  requires  to  be  fed;  he 
loses  himself  every  moment  in  his  own  room;  and  his  ignorance  of  danger 
renders  it  necessary  that  others  should  protect  him  against  accidents. 
His  conduct  is  uniform,  and  always  the  same;  sometimes  apparently 
concentrated  in  self — shy,  dull,  silent,  and  inert;  sometimes  automatic 
movements  are  gone  through — swaying  to  and  fro  of  the  body,  rubbing 
the  hands,  murmuring,  making  unmeaning  noises,  etc.  The  gestures 
are  lifeless — the  countenance  is  relaxed  or  amazed,  or  apparently  atten- 
tive without  motive,  and  the  vacant  look  and  bursts  of  laughter  show 
that  there  exist  no  ideas  which  the  patient  can  express.  Nevertheless, 
they  sometimes  express  slight  symptoms  of  pleasure  or  displeasure  and 
traces  of  emotion;  of  preference,  from  custom  or  with  a  motive,  for  par- 
ticular persons;  of  the  sense  of  shame,  of  childish  pleasure  in  mischief,  of 
anxiety  (hiding  themselves),  etc.  In  their  better  moments,  there 
come  back  to  tiiem  reminiscences  of  former  life,  a  greater  participation 
and  pleasure  in  the  external  world,  and  a  lively  appreciation  of  kind 
treatment;  and  there  is  in  these  lingering  traces  of  self-consciousness  and 
emotion  enough  to  make  us  respect  human  nature,  even  in  this  its  state 
of  deepest  degradation — in  these  unfortunates,  whose  silent,  inexplicable 
gestures  often,  unconsciously  to  themselves,  reveal  a  melancholy  past. 

Serious  disorders  of  tlie  motory  and  sensitive  functions  of  the  brain 
very  frequently  accompany  this  sad  mental  state,  in  particular  entire 
paralysis  of  movement,  and  frequently  also  of  sensation,  so  that  the  pa- 
tient can  often  endure  the  deepest  and  most  extensive  burns  without  any 
feeling  of  pain.  The  nutrition  may  remain  for  a  long  time  unimpaired; 
the  patients  remaining  corpulent,  eating  with  a  voracious  appetite,  etc. 
Sleep,  too,  is  often  well  maintained,  being  sound  and  prolonged. 

The  only  mode  of  termination  of  these  states  is  death.  The  patients 
sometimes  succumb  to  the  apoplectiform  attacks  which  occur  during  the 
course  of  general  paralysis,  or  to  serous  effusions  in  the  brain,  to  cerebral 
atrophy,  or  to  chronic  and  acute  disease  in  other  parts — pneumonia,  gan- 
grene of  the  lung,  tuberculosis,  intestinal  catarrh.  Some  die  from  want 
of  proper  care,  owing  to  retention  of  urine  or  of  fajcal  accumulations,  or 
in  conseqnence  of  accidents,  burns,  choking  by  taking  too  Icrge  mouth- 
fuls  of  food,  etc. 

Senile  dementia,  too,  terminates  in  the  way  we  have  just  described,  as  also 
many  analogous  conditions  sometimes  observed  in  the  prime  of  life,  and  proceed- 
ing froni  atrophy  of  the  brain  with  or  without  arterial  degeneration.  These 
lamentable  cases  of  primary,  slowly  commencing,  progressive  dementia,  often 
proceeding  to  complete  mental  destruction,  occur  in  the  prime  of  life  among  high 
and  low  ;  among  the  former,  sometimes  in  distinguished  men,  owing  to  exces- 
sive mental  and  bodily  exertion  and  irritation.  It  is  often  very  difficult  to  distin- 
guish the  commencement  of  these  conditions  fi'oni  mental  exhaustion  and 
apathy,  which  may  be  caused  by  simple  anaemia.  Slight  numbness  of  the 
extremities  and  symptoms  of  muscular  convulsions  may  also  exist  in  the  latter- 
mentioned  cases.  It  is  frequently  not  until  after  long  observation  that  a  conclu- 
sion can  be  ai-rived  at ;  the  treatment  must  be  nutrient  and  tonic,  all  causes  of 
irritation  being,  of  course,  removed.  Those  cases  in  which  a  primary  state  of 
mental  weakness  has  for  a  long  time  preceded  an  attack  of  apoplexy  or  of 
encephalitis,  generally  depend  upon  disease  of  the  cerebral  arteries. 


244:  STATES    OF    MEJSfTAJL    WEAKNESS. 

Sectioi^  IV. — Idiocy  and  Cretinism. 

§  155.  By  the  term  idiocy,  we  are  to  understand  those  conditions  in 
which  a  state  of  mental  weakness  has  existed  from  birth  or  from  early  in- 
fancy, and  in  which  the  psycliiad  develoiiment  has  been  thereby  impeded 
or  'prevented.  Individuals  in  these  circumstances  remain  to  a  greater  or 
less  extent  below  the  average  in  intelligence;  nor  can  they_  attain  to  the 
degree  of  education  and  instruction  corresponding  to  their  age  and  social 
position. 

While  psychologists  are  generally  agreed  as  to  this  definition  of 
idiocy,  they  are,  on  the  other  hand,  far  from  being  at  one  as  to  the  signi- 
ficance which  the  originally  popular  expression  cretinism  should  bear  in 
science.  Most  frequently,  however,  the  term  cretinism  is  applied  to  a 
particular  species  of  idiocy,  namely,  that  in  which  the  subject  presents  a 
hereditary  defect  of  physical  conformation:  it  is  in  this  sense  that  we 
shall  here  employ  the  word.  This  physical  defect  need  not  of  necessity 
be  always  the  same — it  is  not  specific:  nevertheless,  there  is  one  form  of 
it,  by  far  the  most  frequent  and  best  known,  everywhere  the  same,  and 
apparently  characteristic;  it  occurs  in  various  parts  of  the  world,  bnt  es- 
pecially in  mountainous  districts,  as  a  widely  spread  disease  depending 
upon  local  causes.  The  prototype  of  this  form  is  alpine  cretinism,  and 
may  be  designated  by  the  term  cretinism  in  the  restricted  sense  of  the 
word.  It  will  be  afterwards  described.  This  form  is  always  endemic; 
occasional  cases  of  sporadic  idiocy  may,  however,  be  developed,  according 
to  the  nature  of  the  physical  defect. 

In  all  possible  forms  of  idiocy  we  can,  considered  from  the  stand- 
point of  the  intellectual  development,  distinguish  several  degrees  of  the 
malady.  It  would  be  useless  to  establish  many  degrees  and  gradations 
minutely  distinguished  from  each  other;  it  is  better  to  distinguish,  in  the 
first  place,  simply,  1st,  the  more  severe  cases  of  intellectual  nullity — de- 
mentia, fatuity;  and,  2d,  the  less  severe  cases  of  simple  mental  weakness 
— weakness  of  mind,  imbecility.  In  cretins  the  degree  of  intellectual 
disorder  (viewed  (/e/ie?Y<%)  is  in  direct  relation  to  the  physical  defect; 
we  therefore  generally  meet  with  both  relations  together;  and  correctly 
distinguish  cretins  and  semi-cretins:  the  latter  states  imperceptibly  pass 
through  many  intermediate  degrees  into  the  state  of  health  without  any 
distinguishing  sign. 

According  to  what  has  been  said,  every  cretin  is  an  idiot,  but  every  idiot  is  not 
a  cretin;  idiocy  is  the  more  comprehensive  term,  cretinism  is  a  special  kind  of  it. 
This  acceptation  of  the  term  is  at  the  present  day,  if  not  general,  at  all  events  the 
most  frequently  adopted;  some  signify  by  the  term  cretinism,  the  highest  degree 
of  congenital  dementia.  Opinions  such  as  are  expressed  in  the  most  recent  work 
of  Guggenbiihl  ('  Zeitschr.  der  k.  k.  Ges.  der  Aerzte  zu  Wien,'  1860,  p.  87)  only 
lead  to  confusion.  "We  may  consider  as  mentally  weak,  and  therefore  on  the 
road  to  cretinism,  (!)  all  children  who  neither  at  home  nor  in  the  school  can  be 
made  accessible  to  the  ordinary  means  of  education  and  instruction." 

In  sporadic  idiocy,  the  physical  conformation  maybe  perfectly  normal;  we 
occasionally  even  meet  with  beautiful  and  well-developed  children  in  a  high  degree 
of  dementia.  As  a  rule,  however,  this  is  not  the  case:  the  bodily  development  is 
generally  involved,  in  particular  it  is  often  far  behind  the  age  of  the  patient;  the 
forms,  especially  of  the  head  and  face,  are  incomplete  and  far  from  beautiful;  but 
in  sporadic  cases  we  never  find  those  well-marked  and  peculiar  defects  in  the  phy- 
sical conformation  which,  owing  to  the  extensive  anomalies  found  in  several  organs 
(for  example,  in  the  thyroid  gland),  may  be  considei-ed  as  an  affection  of  the  whole 
constitution.  The  attempt  to  compare  every  qualitative  peculiarity  of  the 
endemic  and  non-endemic  idiocy  appears  to  me  to  be  at  present  premature, 
although  i-t  found  in  Ziliner  an  original  and  well-informed  advocate. 


STATES    OF    MENTAL    WEAKNESS.  24:5 

A.  Idiocy  in  general. 

§  156.  The  essential  character  of  all  idiotic  states  is  iveakness  of  the 
intellect,  as  the  fundamental  faculty  of  the  mind;  a  weakness  which  in 
many  cases  may  be  recognized  in  all  the  phases  of  tlie  mental  life  equally, 
wiiile  in  others  certain  psychical  processes — for  example,  the  emotions — 
are  still  allowed  a  certain  degree  of  activity,  or  even  certain  great  series 
of  ideas  remain  free  and  capable  of  a  moderate  degree  of  development 
(special  aptitudes,  talents  displayed  by  certain  idiots).  From  the  circum- 
stance that  the  weakness  of  perception  is  itself  the  fundamental  disorder, 
idiocy  is  entirely  distinguished  from  the  psychical  imperfections  depen- 
dent upon  deficiency  of  the  senses,  such  as  deaf-dumbness.  From  the 
circumstance  that  this  weakness  comes  on  at  an  early  period  of  life,  and 
that  therefore  the  psychical  development  is  annulled,  or  at  least  much  re- 
tarded, it  is  distinguished  from  dementia  developed  during  the  subsequent 
years  of  life  when,  as  is  indeed  very  often  the  case,  tlie  state  of  weakness 
arose  after  an  originally  normal  mental  state,  or  even — which  happens 
more  rarely — was  ushered  in  by  a  preliminary  stage  of  exaltation. 

It  is  beyond  doubt  that  the  weakness  of  the  intollect,#and  therewith 
the  arrest  of  the  psychical  development,  depends  upon  a  cerebral  anomaly. 
Tliis  fact  is,  in  general,  much  more  capable  of  being  directly  proved  and 
demonstrated  than  in  other  mental  diseases.  In  many  cases  of  idiocy 
there  may  be  observed  considerable  pathological  changes  in  the  brain  or 
its  membranes,  on  an  average  much  more  so  than  in  mental  disease  in  the 
restricted  sense  (§  159);  and  we  can,  in  general,  say,  supported  by  the 
great  majority  of  cases,  that  the  deficient  mental  development  is  the  direct 
result  of  deficient  cerebral  develojjment  in  childhood,  and  that  it  is  in 
proportion  to  it.  Nevertheless,  evident  and  palpable  changes  in  the  brain 
or  its  membranes  are  not  always  found  in  idiocy,  and  we  are  impelled,  by 
numerous  facts,  to  the  assumption  that  there  are  also  idiotic  states,  where 
the  weakness  of  perception  does  not  depend  upon  organic  changes,  but 
originally  upon  a  simple  functional  anomaly  of  the  brain.  To  this  class 
ought  many  cases  to  be  referred,  where  frequent  epileptic  attacks  in  very 
early  life,  or  where  onanism,  commenced  at  a  very  early  period,  have  in- 
duced an  early  exhaustion  of  the  cerebral  functions;  others,  where  long 
general  illness  in  a  child,  with  impairment  of  the  nutrition  of  all  the 
organs,  included  the  brain,  and  therefore  the  due  performance  of  its 
functions;  further,  cases  where  the  mental  development  remains  station- 
ary from  want  of  any  external  mental  impulse — from  extreme  neglect  and 
inattention,  associations  with  other  dements,  unfavorable  outward  rela- 
tions, etc. ;  finally,  certain  cases  where  the  mental  development  does  not 
progress,  because  in  weakly  children  there  exists  such  an  excessive  degree 
of  emotional  irritability,  of  timidity  and  fear,  that  a  state  of  passionate 
excitement  is  awakened  by  every  attempt  at  mental  influence,  even  by  any 
lively  sensorial  impression,  so  that  development  of  the  normal  j^rocess  of 
perception  is  rendered  impossible.  Although  few  of  the  latter  cases  ori- 
ginally belong  to  the  idiotic  states,  still  they  have  the  same  practically 
important  result — arrest  of  mental  development.  But  these  cases  of 
merely  functional  cerebral  disorder,  which  at  the  commencement  consti- 
tute a  more  apparent  dementia,  form  a  very  small  minority  compared 
with  the  cases  where  the  psychical  disorder  is  the  result  of  organic  changes 
in  the  brain. 

On  the  other  hand,  tliose  cases  which  now  and  then  occur  of  great  dulness  or 
absence  of  euiotion,  existing  from  early  infancy,  and  which  are  manifested  in  a 


246  STATES    OF    MENTAL   WEAKNESS. 

precocious  perversity  of  the  desires,  often  as  rudeness,  wickedness,  savageness, 
etc.,  do  not  belong  to  idiocy,  although  they  are  in  a  certain  sense  psychical  de- 
fects, and  are  sometimes  spoken  of  as  cases  of  moral  idiocy,  stunting  of  the  senti- 
ments, etc.  These  states  may  be  associated  with  good  as  well  as  with  bad  natural 
talents,  and  are  not  necessarily  due  to  arrest  of  development  of  the  psychical 
functions. 

§  157.  The  causes  of  tlie  various  cerebral  diseases  which  form  the 
organic  basis  of  idiotic  states  correspond  in  many  rehitions  with  the  causes 
of  the  other  psychical  diseases  (see  Book  II.):  nevertheless,  there  is  here 
much  that  is  peculiar  and  special. 

It  is  evident  that,  in  many  cases,  powerful  causes  exist  in  the  parents 
which  influence  the  developing  germ  which  afterwards  becomes  an  idiot. 
In  families  where  epilepsy,  mental  diseases,  paralytic  affections,  deaf- 
dumbness,  are  frequent,  idiocy  is  also  observed  to  be  common.  Frequently 
it  occurs  as  a  mere  partial  phenomenon,  as  an  individual  manifestation  of 
a  general  deterioration  of  a  race:  thus  we  see  in  a  number  of  brothers  and 
sisters,  one  or  two  idiots,  together  with  others  who  are  small,  incompletely 
developed,  ugly,  and  sterile.  These  degenerations  are  principally  observed 
in  families  where  the  blood  has  not  been  sufficiently  renewed;  where  the 
marriages  have  always  been  with  near  relatives;  also  where  the  parents 
have  been  too  old  or  too  young,  or  addicted  to  drunkenness.  _  Sometimes 
all  the  children  of  such  marriages  bear  evident  marks  of  idiocy,  or  of 
some  otlier  form  of  degeneration;  indeed,  in  certain  cases  this  may  be 
recognized  as  increasing  from  the  first  to  the  last  child,  so  that,  for 
example,  the  last  or  the  two  last  are  quite  demented — the  others  stunted 
in  growth,  hysterical,  nervous,  epileptic,  deaf-and-dumb,  etc.  At  other 
times  some  of  the  children  are  perfectly  healthy;  but  this  does  not  render 
the  statement  incorrect,  that  idiocy  is  a  mark  of  degeneration  of  race  in 
that  family:  at  the  time  of  conception  of  tlie  various  children,  the  state 
of  health  of  the  parent  may  sometimes  increase,  sometimes  considerably 
diminish,  the  influence  of  the  constant  (tending  to  degeneration)  causes. 

The  shallow  doctrine  which  has  recently  been  promulgated,  that  mental 
disease,  drunkenness,  etc.,  of  the  parents,  does  not  so  much  influence  the  germ 
as  it  favors  of  the  development  of  the  idiocy— that,  under  such  relations,  the  care 
and  education  of  the  children  must  necessarily  be  neglected— can  easily  be  re- 
futed by  the  results  of  observation  of  idiocy  in  the  higher  and  even  the  highest 
ranks  of  life.  This  hypercritical  questioning  the  hereditariness  of  idiocy  can, 
generally,  only  lead  from  the  way  of  truth  (see  t^S  9^,  93),  and  its  hereditariness 
may  be  accepted  in  the  same  wide  sense  as  that  of  other  mental  diseases  (§  93). 
In  a  case  which  came  under  my  observation,  the  father  of  a  highly  idiotic  child 
suffered  from  violent  periodic  headaches,  during  which  he  sometimes  quite  lost 
his  senses:  the  brother  of  the  father  was  likewise  disposed  to  frequent  headaches 
(see  §  92).  In  another  case  which  I  observed,  the  father  of  an  idiotic  boy  lived  in 
ahaiaitual  state  of  excitement,  as  if  he  were  always  intoxicated:  the  brother  of 
the  father  was  an  idiot. 

Another,  but  little  known,  series  of  causes  acts  during  the  fo-tal 
period.  Dul-ing  this  period  various  errors  of  development  and  diseases 
of  tlie  brain  and  its  membranes  may  occur,  to  which  sometimes  external 
injuries  may  give  the  impulse,  for  which,  however,  much  more  frequently, 
no  direct  mechanical  cause  can  be  discovered.  Great  anemia  of  the 
mother,  drunkenness,  violent  shock  and  grief  during  pregnancy,  appear 
not  to  be  without  influence.  In  certain  rare  cases,  injury  to  the  head 
during  childbirth  may  exert  an  injurious  effect. 

Far  more  frequently,  however,  those  diseases  which  lead  to  idiocy 
(also  those  which  are  hereditary)  do  not  commence  until  after  birth,  from 
then  till  within  the  third  or  fourth  year;  in  exceptional  cases,  till  the 


STATES    OF    MENTAL    WEAKNESS.  247 

fifth  or  even  the  seventh  year.  They  commence  and  run  sometimes  an 
acute,  sometimes  an  insidious  chronic  course;  they  consist  in  congestive, 
inflammatory,  or  other  derangement  of  the  nutrient  processes,  more 
rarely  in  sanguineous  extravasations  in  the  brain  and  its. membranes,  very 
frequently  in  affections  of  the  cranial  bones.  Bad  care  and  ill-adapted 
nourishment  to  very  young  children;  keeping  the  head  too  hot;  the  use 
of  coverings  which  compress  the  head;  the  use  of  opiates;  injuries  and 
shocks  to  the  head,  and  other  injurious  influences  of  a  like  nature;'  other 
diseases  of  childhood — as  acute  exanthemata,  weakening  of  the  infantile 
constitution  by  various  causes,  in  some  cases  syphilis" — appear  at  this 
period  to  exert  the  greatest  influence  on  the  origin  of  those  cerebral  affec- 
tions. The  influence  of  early  commencing  epilepsy,  or  irritation  of  the 
sexual  organs  at  an  early  age  and  its  consequences,  and,  finally,  the  influ- 
ence of  total  mental  neglect  and  association  with  other  idiotic  children,  is 
likewise  not  to  be  lightly  estimated. 

Finally,  there  are  a  series  of  powerful  local  causes,  peculiar  to  certain 
localities,  which  we  at  present  must  consider  to  be  miasmatic  in  their 
nature;  with  the  progress  of  science,  however,  we  may  be  yet  able  to  ana- 
lyze the  individual  circumstances.  These  causes  lie  at  the  foundation  of 
endemic  cretinism,  and  will  be  afterwards  considered  more  in  detail.  But 
house  and  chamber  miasms,  owing  to  dampness,  vitiated  or  too  seldom 
renewed  air,  uncleanliness,  appear  to  be  capable  of  exerting  quite  an  ana- 
logous action;  the  long-continued  residence  of  young  children  in  such 
chambers  is  therefore  especially  injurious.  The  ''cretinism  of  large 
towns,"  amongst  the  inhabitants  of  low-lying,  overcrowded,  badly-venti- 
tilated,  cold  houses,  is  certainly  to  be  in  part  attributed  to  miasmatic 
causes — together  with  a  number  of  other  co-operating  influences.  Mias- 
matic causes  act  more  upon  the  origin  of  diseases  of  the  cranial  bones 
than  upon  affections  of  the  brain  itself  or  its  membranes;  they  act  partly 
upon  the  foetus,  partly  upon  the  child  after  birth. 

§  158.  We  have  seen  that  the  great  majority  of  cases  of  idiocy  depend 
upon  palpable  anomalies  of  the  brain  and  its  membranes,  and  have  now 
to  determine  what  these  anomalies  are.  If  these  were  known  to  us,  it 
would  be  extremely  interesting  to  compare  the  various  anatomical 
changes,  according  to  their  nature,  their  seat,  etc.,  with  the  different 
kinds  of  mental  defects.  We  might  hope  in  this  way  to  come  nearer  to 
the  relations  of  certain  parts  of  the  brain  to  certain  faculties  of  the  mind, 
and,  in  a  practical  point  of  view,  to  arrive  at  the  elements  of  an  anatomi- 
cal diagnosis  during  life.  Nevertheless,  we  soon  become  convinced  that, 
with  our  present  material,  certain  by  no  means  unimportant  results  in 
these  directions  may  be  arrived  at  (see  §  166),  but  the  principal  part  of 
the  work  cannot  at  present  be  undertaken.     In  a  great  number  of  the 


'  See  Kostl,  '  Der  endemische  Cretinismus,'  etc.,  Wien,  1855,  p.  9.  "  In  the 
Bruck  circuit,  forty-eight  notable  cases  of  children  are  known  whose  idiocy  is 
ascribed  to  a  fall  on  the  head  from  a  height."  In  this  work  we  find  a  number  of 
contributions  to  that  part  of  etiology  which  depends  vipon  ignorance  of  the 
parents  or  guardians,  or  upon  popular  opinions. 

2  Erlenmeier  has  recently  published  the  case  of  an  idiotic  child,  where  the 
cranium  presented  numerous  exostoses,  and  who  recovered  under  the  influence 
of  iodide  of  potassium.  The  case  of  Guislain  (•  Leg.  or.,'  ii.,  p.  98),  where  a  child 
begotten  of  a  powerful  man  while  undergoing  a  course  of  mercury  (for  syphilis), 
whose  former  and  subsequent  children  were  perfectly  healthy,  was  idiotic:  this 
case  is  interesting,  although  it  has  no  direct  bearing  upon  the  question  of  the  in- 
fluence of  syphilis. 


248  STATES    OF    MENTAL    WEAKNESS. 

cases  now  under  consideration,  tlie  psycliological  analysis  is  so  defective; 
the  manifestations  of  mental  life,  especially  in  idiotic  children  who  die 
early,  are  so  exceeding  scanty;  the  changes  found  in  the  brain  are  often 
,  so  incorrectly  described;  especially,  however,  there  so  frequently  exist 
several  cerebral  changes, — that,  in  a  theoretical  point  of  view,  we  must 
at  present  renounce  more  minute  explanations,^  and  content  ourselves 
with  collecting  and,  in  a  measure,  arranging  the  material.  For  the  prac- 
tical anatomical  diagnosis,  however,  we  must  depend  more  on  the  results 
afforded  by  direct  examination  of  the  head,  on  the  etiology  and  on  certain 
motory  anomalies,  than  on  the  particular  form  of  the  mental  weakness. 

In  general,  we  do  not  find  the  organic  cause  of  idiocy  to  be  a  recent 
and  still  progressing  morbid  process  in  the  brain,  but  either  actual  arrest 
of  develojmient,  or  states  consecutive  to  and  remnants  of  former  morbid 
processes:  as  we  have  seen,  these  may  have  originated  during  intrauterine 
life,  or  after  birth  from  the  first  to  the  fifth  or  sixth  year,  and  in  certain 
cases  even  later.  In  particular,  we  must  distinguish  between  anomalies 
which  originally  and  primarily  involve  the  brain,  and  such  as  in  the  first 
place  constitute  an  abnormality  of  the  skull,  by  which,  secondarily,  the 
proper  development  and  form  of  the  brain  is  involved.  We  must,  of 
course,  remain  undecided  as  to  many  cases  which  maybe  presented  to  us; 
but  we  may  expect  that  the  distinctive  signs  will  become  gradually  more 
distinct  and  more  certain:  this  distinction,  as  one  regarding  a  funda- 
mental process,  is,  as  far  as  possible,  to  be  maintained.  In  the  following 
enumeration  of  the  anomalies  which,  according  to  experience,  are  pre- 
sented in  idiocy,  we  shall  endeavor,  as  far  as  possible,  to  carry  out  this 
distinction. 

§  159.  Of  these  anomalies,  ^oyer^?/  of  the  hrain,  in  its  various  modifica- 
tions, takes  the  lead.  Abnormal  smaUness  of  the  entire  brain  (generally 
well  pronounced  in  the  convolutions),  with  microcephalus,  is  to  be  regarded 
as  an  arrest  of  development,  of  which  the  source  is  sometimes  in  the 
brain  itself,  and  sometimes  in  the  cranium.  The  latter  appears  to  be 
the  more  common,  and  it  is  principally  the  jjremature  ossification  of  the 
entire  cranium  which  confines  the  brain  and  prevents  its  normal  expan- 
sion. Very  early  occlusion  of  the  fontanelles  (which  is  sometimes  even 
complete  at  birth),  premature  ossification  of  a  great  many  of  the  sutures 
of  the  skull,  hinder  the  rapid  growth  in  the  early  periods  of  life  which 
is  characteristic  of  the  human  brain  (in  none  of  the  lower  animals  do  the 
fontanelles  remain  long  open);  and  this  injurious  influence  on  the  cere- 
bral development  is  greater  according  as  the  compensation  which  occurs 
through  the  expansion  of  other  parts  is  less.  In  the  other,  less  numerous 
class  of  microcephalics,  all  the  cranial  sutures  remain,  even  to  adult  life 
(whereby  the  cranium  may  be  either  well  proi^ortioned  or  unsymmetrical); 
and  the  sources  of  the  defective  development  of  the  brain  must  lie  within 
the  organ  itself,  or  the  cranium  remains  small  with  the  brain.  The 
brain  itself  may  in  both  series  of  cases  be  simi:)ly  small — a  miniature  brain, 
without  other  anomaly  or  defect,  and  properly  proportioned  in  all  its 
parts:  more  frequently,  there  also  exist  other  changes,  particularly  scle- 
roses, hydrocephalus,  unequal  size  of  the  hemispheres,  or  other  form  of 
dis-symmetry. 

1  We  expect  to  receive  information  on  these  points  from  the  idiot  institutions, 
just  as  correct  ideas  regarding  mental  disease  were  first  received  from  the 
asylums. 


STATES    OF    MENTAL    WEAKNESS.  249 

In  many  mici'ocephalics  the  brain  is  even  smaller  than  might  be  presumed 
from  the  external  aspect  of  the  cranium,  owing  to  the  occasional  enormous 
thickness  of  the  bones  of  the  skull,  and  to  the  occasional  existence  of  a  consider- 
able amount  of  hydrocephalus. 

Baillarger  ('Acad,  de  Med.,'  29  Jul.,  1856)  has  reported  cases  in  which  the 
fontanelles  were,  even  at  birth,  to  a  great  extent  ossified.  Cruveilhier  has  seen  a 
case  where  there  was  synostosis  of  all  the  sutures  at  the  age  of  eighteen  months; 
cases  in  which  many  of  the  sutures  are  already  ossified  at  the  age  of  3-4  are  by 
no  means  ^are.  Also  Virchow  ('Gesamm.  Abhandl.,'  Frankf.,  1856,  p.  905)  has 
described  microcephalic  skulls  in  which  all  the  sutures  existed.  I  myself  have 
recently  examined  the  cranium  of  a  girl,  aged  nineteen,  who  died  at  Mariaberg; 
she  presented  the  appearance  of  a  child  of  ten  or  twelve  yeai's  of  age,  had  been 
•epileptio  and  quite  idiotic  (uninterrupted  state  of  profound  dreaminess,  complete 
dumbness,  incapacity  to  walk  or  to  stand).  The  cranium,  which  was  very  small, 
very  short,  and  incliiied  to  the  right  side  and  forwards,  presented  all,  even  the 
frontal  suture,  without  trace  of  ossification.  Another  cranium,  sent  to  me  from 
the  asylum  at  Winterbach,  and  whicli  had  belonged  to  an  idiotic  woman  twenty- 
one  years  of  age  (weight  of  the  brain,  06  loth — about  18  ounces — tlie  left  hemi- 
sphere very  short),  was  not  so  large  as  the  skull  of  an  ordinary  child  of  seven 
years.  It  did  not,  however,  present  any  striking  abnormality  of  form,  being  only 
a  little  unsymmetrical;  the  frontal  suture  was  completely  obliterated,  the 
sagittal  suture  was  incomplete  anteriorly,  posteriorly  quite  ossified:  the  other 
sutures  were  well  preserved. 

(Concerning  a  remarkable  case  of  miniature  brain  which  Baillarger  and  Gra- 
tiolet  examined,  see  'Acad,  de  Med.,'  26  Mai,  1857.  The  brain  was  that  of  a 
female  Aztec  child  (4$  166);  it  was  perfectly  well  formed,  and  presented  no  trace 
■of  hydrocephalus;  it  was,  however,  so  little  developed,  that  it  resembled  the 
brain  of  a  foetus  in  the  seventh  or  eighth  month. 

Under  the  head  of  general  poverty  of  the  brain,  may  also  be  ranged  those 
cases  in  which  the  convolutions  are  remarkably  simple,  although  the  volume  of 
the  brain  is  not  much  below  the  average;  these  cases  present  at  least  a  notable 
diminution  of  the  cerebral  surface. 

In  idiots  the  brain  is  frequently  diminished  in  vohime  in  certain  parts, 
or  it  may  even  present  certain  defects.  The  following  are  the  principal 
varieties: — Sometimes  the  cerebral  hemispheres  are  imperfectly  developed 
in  certain  parts,  most  frequently  in  the  anterior  lobes  (when  the  antero- 
posterior diameter  of  the  cranium — as  frequently  haj^pens — is  diminished, 
the  cerebral  hemispheres  are  necessarily  shortened,  but  this  is  generally 
most  strikingly  manifested  in  the  anterior  lobes),  when  there  is  often 
remarkable  stunting  of  the  olfactory  bulbs,  sometimes  also  of  the  pos- 
terior lobes,  when  the  cerebellum  is  not  so  completely  covered  as  usual 
or  not  completely  covered  by  the  cerebrum;  those  parts  which  are  insuf- 
ficiently developed  may  present  few  but  moderately  developed  convolu- 
tions, or  they  may  be  very  small,  as  if  atrophied,  or  as  if  they  remained 
^t  an  early  childish  stage.'  Inequality  of  the  ttvo  halves  of  the  brain, 
particularly  of  the  cerebral  hemispheres,  must  not  be  attributed  to  hyper- 
trophy of  tlie  greater,  but  to  atrophy  of  the  smaller  half;  and  this 
abnormal  smallness  may  be  the  result  of  a  deformity  of  the  cranium 
(unilateral  stenosis),  or  of  an  original  deficiency  in  the  development  of 
the  brain,  or  of  arrest  and  atrophy  in  consequence  of  encephalitic,  apo- 
plectic, or  other  processes,  of  which  palpable  traces  may  sometimes  subse- 
quently be  found  (brown  or  yellow  spots,  small  deficiencies  in  the  cerebral 
substance,  etc.).     In  this  respect  all  degrees  exist,  from  the  slightest 

•  The  latter  condition,  the  apices  of  the  two  posterior  lobes  moderately  but 
symmetrically  diminished  in  volume,  I  recently  observed  in  an  individual,  aged 
twenty-three,  who  had  never  been  idiotic,  but  had,  on  the  contrary,  exhibited 
a  moderate  degree  of  intelligence  and  read  a  great  deal.  He  had  never  manifested 
any  sexual  desire  (this  came  to  be  inquired  into,  as  he  was  diabetic).  The 
cerebral  hemispheres  did  not  completely  cover  the  cerebellum. 


250  STATES    OF    MENTAL    WEAKNESS. 

shortening  to  the  state  where  a  whole  hemisphere  has  almost  totally 
disappeared,  and  is  transformed  into  ameshwork  filled  with  serum;  even 
in  moderate  degrees  the  substance  of  the  lesser  hemispheres  is  often 
changed,  coriaceous,  compact  (sclerosity),  the  lateral  ventricles  dilated, 
the  choroid  plexus  thickened,  etc.  The  dis-symmetry  frequently  extends 
to  the  cerebellum,  pons  Varolii,  and  medulla  oblongata;  in  particular, 
the  cerebellum  often  participates  in  it  when  the  atrophy  results  from 
shortening  of  the  cranium;  and,  as  it  appears,  this  atrojjhy  is  sometimes 
on  the  same  side  as  the  atrophied  cerebral  lobe,  sometimes  on  the  oppo- 
site side;'  there  frequently  exist  atrophy,  paresis,  convulsions  of  the 
opposite  half  of  the  body  (the  condition  which  has  in  recent  times  been 
described  as  "  unilateral  atrophy,  "and  which  is  not  always  associated  with 
idiocy).  Little  attention  has  as  yet  been  paid  to  atropliy  of  the  medulla 
oblongata  and  inequality  and  asymmetry  of  many  j^arts  of  the  base  of  tlie 
brain  in  idiots.  These,  however,  will  appear  more  important  in  propor- 
tion as  the  osseous  basis  cranii  is,  through  recent  investigations,"  recog- 
nized as  the  point  of  origin  of  the  disorder  in  very  many  cases  of  idiocy. 

In  the  forementioned  microcephalic  girl  from  Mariaberg,  I  found  the  follow- 
ing abnormalities  in  the  pons  Varolii  and  medulla  oblongata:— the  pyramids  were 
alike  on  both  sides;  the  left  olivary  body  was  somewhat  shorter  than  the  right, 
especially  at  its  inferior  part;  the  left  processus  cerebelli  ad  pontem  was  weaker, 
smaller,  and  on  its  anterior  and  lateral  border  as  if  bent  inwards;  on  the  left  half 
of  the  pons  Varolii  the  oblique  band  of  fibres  (ruban  fibreux  of  Foville,  coming 
from  the  corpus  restif orme)  was  much  more  pronounced,  separated  on  its  lower 
border  from  the  more  horizontal  fibres  of  the  pons  by  a  deep  groove;  in  the 
fourth  ventricle  the  tuber  cinereum  at  the  point  of  the  calamus  was  less  developed 
than  the  right;  the  left  hemisphere  of  the  cerebellum  was  a  little  smaller  but 
somewhat  higher  than  the  right.  In  the  work  of  Demme,  'Ueber  ungleiche 
Grosse  beider  Hirnhalften,'  Wiirzburg,  1831,  there  ai-e  many  analogous  examples 
of  inequality  of  the  two  halves  of  the  pons  Varolii,  of  the  two  sides  of  theepinal 
cord,  and  the  two  olivary  bodies.  The  same  condition  has  been  observed  by 
Valentin  in  an  idiotic  child  from  Abendberg :  anomalies  also  in  the  pyramidal  and 
olivary  bodies  were  seen  in  a  case  by  the  Sardinian  Commission  on  Cretinism 
('  Rapport,'  etc.,  p.  204).  The  entire  spinal  cord  appears  to  be  atrophied  in  some 
cretins  (case  of  Eulenberg  and  Marfels;  Niepce,  ninth  autopsy);  this  forms  an 
important  subject  for  further  investigation,  especially  in  individuals  suffering 
from  paralysis  with  convulsions,  etc.  Case  of  spina  bifida  together  with  hydro- 
cephalus have  also  been  observed. 

HeschP  has  described,  under  the  name  of  porencephalus,  those  cere- 
bral defects  in  which  a  lai-ge  portion  of  the  convolutions  and  centrum 
semiovale  is  wanting,  in  such  a  manner  that  a  person  may  look  through 
the  aperture  straight  into  the  ventricle;  this  is  filled  with  serum  which  is 
contained  in  a  bladder  or  meshwork  of  the  pia  mater;  sometimes  the  cor- 
responding part  of  the  cranium  projects  outwards. 

Porencephalus  does  not  appear  to  be  produced  by  actual  arrest  of  development 
of  the  affected  part  of  the  brain,  but  rather  by  an  intrauterine  disease  which  at  a 
verv  early  period  destroys  the  part.  In  nearly  every  case  of  this  kind  there  is 
idiocy,  ^vith  more  or  less  paralysis  and  contraction  of  the  opposite  half  of  the 
body ;  in  cases  presenting  these  symptoms,  especially  if  there  be  a  prominence  on 


1  See  Virchow,  '  Entwicklung  des  Schadelgrundes,'  Berlin,  1857,  j).  114. 

2  Virchow  has,  in  his  work  on  the  Physiognomy  of  Cretins,  particularly  called 
attention  to  the  fact  that  slight  deviations  in  form  of  the  pons  Varolii,  the 
medulla  oblongata,  and  the  fourth  ventricle,  may  originate  through  spheno- 
basilar  synostosis. 

'<"  Prager  '  Vierteljahrschrift,'  Bd.  Ixi.,  1859,  p.  59.  A  self -observed  and  three 
other  cases. 


STATES    OF    MENTAL    WEAKNESS.  251 

one  side  of  the  skull,  the  existence  of  this  lesion  may  be  presumed  (Heschl). 
Tilngel  ('Clin.  Mittheil.,'  Hamburg,  1860,  p.  65)  has  recently  published  an 
analogous  case  where  the  subject,  a  man  forty-seven  years  of  age,  had  suffered 
from  mental  weakness,  dementia,  but  had  neither  been  paralytic  nor,  strictly 
speaking,  idiotic. 

As  further  but  more  rare  anomalies  met  with  in  idiots,  may  be  men- 
tioned numerous,  more  localized,  cerebral  defects,  deficiency  or  extraordin- 
ary smallness  of  the  most  varied  structures  of  the  organ;  indeed;  there  is 
scarcely  any  portion  of  the  brain  Avhich  has  not  been  found  either  alto- 
gether absent  or  quite  rudimentary  in  these  creatures.  Thus,  there  are 
examples  of  absence  of  the  entire  cerebellum;'  of  deficiency  of  the  pineal 
gland;'  of  defects  of  the  fornix  (Niepce  in  several  of  his  autopsies);  of  a 
rudimentary  condition  of  one  or  of  both  olivary  bodies,  peduncles,  cor- 
l)ora  mamillaria,  thalamus  and  corpus  striatum;  of  atrophy  of  the  optic 
commissure,  deficiency  of  the  auditory  nerves  (Valentin);  finally  absence 
or  rudimentary  state  of  the  corpus  callosum :  of  this  anomaly,  about  a  dozen 
cases,  many  of  them  very  interesting,  have  been  pubhshed. 

Some  of  these  cases  of  deficiency  of  the  corpus  callosum  were  profoundly 
idiotic;  this  appeared  to  be  the  case  only  in  those  where  other  defects  or 
anomalies  were  presented  by  the  brain.  To  these  belong— 1st,  the  case  of  Bi- 
anchi  (1748,  quoted  by  Forge  child  of  seven  years,  profoundly  idiotic;  complete 
absence  of  the  corpus  callosum,  both  hemispheres  and  the  thalami  and  corpora 
striata  run  together  in  one  mass;  there  was  no  pituitary  body;  there  was  some 
trace  of  the  pons  Varolii,  but  none  of  the  pyramids  and  olivary  bodies.  2d,  the 
case  of  Forg  (Die  Bedeutung  des  Balkens,' etc.,  Miinchen,  1855;  girl,  seventeen 
years  of  age,  in  the  highest  degree  idiotic,  and  badly  developed  physically;  the 
middle  free  part  of  the  corpus  callosum  was  entirely  wanting,  likewise  the 
septum,  the  middle  part  of  the  fornix;  of  the  anterior  and  white  commissures 
of  the  gyrus  fornicatus,  only  a  rudiment  exists;  the  island  of  Reil  is  considerably 
atrophied;  the  convolutions  are  abnormally  grouped,  many  of  them  entirely  ab- 
sent; the  lobes  of  the  cerebellum  are  unsymmetrical;  hydrocephalus.  3d,  the 
case  of  Chatto  ('London  Medical  Gazette,'  vol.  i.,  1845):  child  of  one  year,  in 
whom  all  intellectual  manifestations  and  sensorial  perceptions  appear  to  have 
been  entirely  wanting;  corpus  callosum,  septum  and  fornix  absent,  except  two 
small  cords  belonging  to  the  corpus  callosum,  and  wnich  hang  in  front  from  each 
hemisphere;  hydrocephalus.  Finally,  several  of  the  nine  autopsies  of  cases  of 
endemic  cretinism  by  Niepce  ('  Traite  du  Goitre,'  etc.,  Paris,  1851,  i.,  p.  25:  ii.,  p. 
Ill)  present  very  great  thinness  or  imperfect  development  of  the  corpus  callosum, 
along  with  other  deficiencies  in  the  brain. 

On  the  other  hand,  there  is  a  series  of  cases  where  there  is  no  profound  idiocy, 
but' merely  a  moderate  degree  of  mental  weakness;  and  sometimes  even  this  does 
not  exist.  Case  of  Reil  ('Arch.  f.  Physiol.,'  Bd.  ii.,  1812,  p.  341):  a  female,  aged 
thirty,  demented,  but  still  able  to  go  messages;  the  middle  free  part  of  the  corpus 
callosum,  the  corpora  geniculata,  the  convolution  of  the  corpus  callosum  and  the 
septum  lucidum  were  entirely  absent;  the  otber  parts  of  the  brain  appear  to  have 
been  normal.  Case  of  Solly  ('The  Human  Brain,'  London,  1826,  p.  433):  a  boy, 
aged  seventeen,  always  mentally  weak,  but  took  delight  in  reading  religious 
books;  was  benevolent,  docile,  sleepy,  inclined  to  stumble  and  fall:  besides  the 
want  of  the  corpus  callosum,  a  cyst  was  found  in  the  brain.  Case  of  Paget 
('Med.-Chir.  Transact.,'  vol.  xxix.,  1846,  p.  55):  girl,  aged  twenty-one,  amiable 
and  childish  disposition,  showed  no  striking  peculiarity,  good  memory,  actions 
rapid  and  inconsiderate,  speech  sharp  and  abrupt;  the  corpus  callosum  was  quite 
rudimentary,  being  represented  by  a  thin  band  of  horizontal  fibres;  the  septum 
and  middle  part  of  the  formix  were  absent.  Case  of  Mitchell  Henry  ('  Med.-Chir. 
Transact.,'  vol.  xxxi.,  1848,  p.  239):  a  boy,  aged  fifteen,  gentle,  but  slow  to  leain, 

'  The  famous  case  of  the  idiotic  girl,  of  eleven  years  of  age,  'Anal.  Path.,' 
livr.  XV.,  pi.  5.  ,„,      ,      . 

»  Schnepff  ("Soc.  de  Biologic,"  'Gazette  Med..'  1850,  p.  894).  The  brain  was 
otherwise  normal;  the  pituitaiy  gland  was  absent;  in  its  place  were  two  con- 
cretions, hard  like  stones.  The  subject  had  been  weak-minded  from  birth,  and 
died  at  the  age  of  twenty -nine. 


252  STATES    OF    MENTAL    WEAKNESS. 

dull,  sleepy,  much  disturbed  when  rapidly  spoken  to;  the  brain  normal;  the  cor- 
pus callosum  represented  by  a  horizontal  band  of  fibres,  H  inch  broad;  the  septum 
and  middle  anterior  part  of  the  fornix  absent.  Case  mentioned  in  the  Rej)ort  of 
the  Vienna  Asylum  for  1858:  a  man,  a^^ed  twenty-five,  in  his  twentieth  year  be- 
came epileptic  in  consequence  of  a  fright,  and  since  then  has  gradually  fallen  into 
dementia;  the  corpus  callosum  absent,  the  anterior  commissure  incomplete;  hy- 
drocephalus. 

§  160.  To  the  anatomical  lesions  most  frequently  met  with  in  the 
brains  of  idiots  belongs  chrojiic  liydrocejihalus,  congenital  or  commenc- 
ing in  early  youth,  and  from  the  most  moderate  to  the  highest  degrees; 
it  is  often  accompanied  by  remarkable  thickening  of  the  lining  membrane 
of  the  ventricles.  In  many  cases,  the  hydrocephalus  seems  to  constitute 
the  primary  and  chief  disease;  this  may  be  assumed  in  those  cases,  es- 
pecially where  the  ossification  of  the  cranium  takes  jilace  slowly,  where 
the  bones  of  the  head  remain  thin,  where  there  is  considerable  or  even 
moderate  increase  of  size  of  the  cranium  (macrocephalus).  In  many 
other  cases,  again,  the  increased  amount  of  serum  in  the  cranium  of  idiots 
is  often  secondary;  a  result  of  limitation  of  development,  of  atrophy  of 
certain  parts — in  short,  of  cerebral  deficiencies  (hydrops  ex  vacuo),  or  it 
is  even  a  more  accidental  comjilication  of  various  malformations  of  the 
brain.  A  convincing  example  of  this  is  afforded  by  the  unilateral  hydro- 
cephalus in  atrophy  of  one  side  of  the  brain.  In  all  these  cases  the  cra- 
nium may  be  of  the  ordinary  circumference,  or  even  (and  very  often),  as 
we  have  already  seen,  considerably  less.  The  volume  of  the  brain  may  in 
every  case  of  considerable  hydrocephalus  be  considered  to  be  diminished, 
and  very  frequently  that  portion  which  remains  is  less  capable  of  jier- 
forming  its  function. 

Rare  but  \erj  interesting  malformations  of  the  head  are  caused  by  partial  hy- 
drocephalus, by  great  dilatation  of  the  lateral  ventricles  in  only  one  part  (for 
•example,  the  inferior  cornu).  Should  this  occur  at  a  period  when  the  skull  still 
consists  in  part  of  the  membranous  elements  of  the  cranial  bones,  symmetrical 
protrusions  are  formed,  in  consequence  of  the  eccentric  pressiu'e  exercised  on  the 
-corresponding  portion  of  the  brain,  sac-like  prominences  on  the  skull.  See  Wil- 
ligk,  Prager  '  Vierteljahrschr.,'  Bd.  1.,  1855,  p.  30;  Lambl,  see  §  161.  A  very  re- 
markable and  very  rare  fact  which  has  been  observed  by  Valentin  and  Niepce  is  the 
presence  of  a  fifth  ventricle  within  the  olives  of  the  cerebellum  (ventric  ciliaris, 
normal  in  the  brain  of  birds).  In  the  first  case  (from  Abendberg)  the  ventricle 
was  from  1  to  \h  inch  long.  Those  idiots  with  considerable  hydrocephalic  en- 
largement of  the  cranium  generally  remain  small,  and  their  entire  development  is 
retrograde,  so  that,  for  example,  at  sixteen  years  of  age  they  appear  like  five  or 
six.  Still,  this  is  not  always  and  necessarily  the  case.  I  myself  know  of  cases 
where  a  considerable  amount  of  hydrocephalus  coexisted  with  a  well-developed 
bod}"  and  pleasant  features.  The  causes  of  these  differences  would  form  an  inter- 
esting subject  of  study. 

Encejyhalitic  2Jrocesses  of  variable  extent,  sometimes  localized,  some- 
times more  diffused  and  terminating  in  different  ways,  but  especially  in 
sclerosis  and  atrojihy  of  the  affected  parts,  constitute  in  many  cases  of 
idiocy  the  principal  anatomical  lesions.  These  may  occur  even  during 
the  embryonic  stage,  during  the  first  months  of  life,  or  the  period  of  the 
first  dentition,  and  sometimes  later,  up  to  the  fourth  or  fifth  years.  In 
those  cases  where  death  does  not  occur  till  long  after  the  disease  has  run  its 
course,  it  frequently  happens  that  the  remains  of  these  processes  are  diffi- 
cult to  distinguish,  and  it  is  principally  through  cicatrices  or  other 
thickenings,  through  pigmentation,  etc.,  that  the  atrophied  parts  (some- 
times a  Avhole  hemisphere)  can  be  distinguished  from  structures  simply 
arrested  in  their  development.      In  these  cases  the  idiocy  is  very  fre- 


STATES    OF    MENTAL    WEAKNESS.  253- 

quently  accompanied  by  a  unilateral  motory  affection  (paresis,  contrac- 
tion), and  sometimes  by  epilepsy.  The  diffused  hypertrophy  of  the 
connective  tissue  of  the  brain  whicii  may,  generally  speaking,  be  referred 
to  chronic  encephalitis,  and  which  is  often  found  in  paralytic  dementia, 
has  been  proved  by  certain  well-marked  examjDles  to  occur  in  idiocy. 

Isambert  has  coiniaunicated  ("See.  de  Biologie,"  'Compt.  rend,  et  Mem.,'  ii , 
2,  1856,  p.  9)  an  interesting  case  of  this  kind  which  was  examined  microscopical l)r 
by  Robin:  it  occurred  in  an  idiotic  child,  two  years  of  age:  the  ventricular  walls, 
the  gi-eat  ganglia,  the  pons  and  peduncles  were  solid  and  hard;  their  tissue  waa 
elastic  like  caoutchouc,  the  nerve  tubes  in  the  white  substance  were  almost  com- 
pletely destroyed,  and  an  amorphous  granular  substance  occupied  their  place: 
there  also  existed  newly  formed  fibrous  connective  tissue. 

In  those  common  cases  in  which  we  are  told  that  a  hitherto  healthy  and  well- 
developed  child,  about  the  period  of  dentition,  or  during  the  second  or  third  year, 
suddenly  became  feverish;  was  attacked  by  convulsions  ("fits'"),  delirium;  fell 
into  a  slight  soporific  state,  and  soon  afterwards  apparently  recovered,  but  the 
intellectual  development  remained  at  a  standstill;  speaking  and  walking,  which 
it  had  recently  commenced,  become  difficult,  but  the  "  fits  "  remain  and  gradually 
pass  into  epilepsy; — in  these  common  cases  there  are  two  processes  which  we  have 
principally  to  consider.  These  are  generally  either  congestive  states  and  slight 
inflammatory  processes  in  the  membranes,  which  may  be  connected  with  ossifi- 
cation (inflammatory)  of  the  sutures  of  the  cranium  or  with  the  general  develoi> 
ment  of  the  infantile  brain,  and  very  frequently  leave  behind  serous  effusions,  or 
a  disposition  to  the  gradual  development  of  hydrocephalus.  Or  they  are  states  of 
encephalitis,  which,  after  the  passing  off  of  the  acute  state  (with  swelling  of  the 
brain,  etc.),  involve  or  suspend  further  development  in  the  affected  parts,  and 
may  often  be  recognized  long  after  in  their  results  at  the  autopsy.  These  pro- 
cesses may  be  assumed,  above  all,  in  cases  where  one  side  of  the  body  is  a  little 
less  developed  than  the  other,  where  convulsions,  paralyses,  contractions,  etc., 
exist,  limited  to  one  side  of  the  body.  As  an  example  of  the  most  severe  form  of 
this  kind,  I  quote  the  following  case  from  Calmeil  ('Malad.  inflammat.  du  Cer- 
veau,'  Par.,  1859,  ii.,  p.  411):  "A  healthy  boy,  during  convalescence  from  measles, 
fell  into  a  violent  convulsive  attack,  which  was  followed  by  prolonged  coma:  he 
came  out  of  this  state  deaf,  dumb,  and  blind;  in  fourteen  days  the  sense  of 
hearing  returned ;  after  the  lapse  of  a  year  he  learned  to  speak  a  few  words,  but 
he  continued  blind,  became  epileptic  and  hemiplegic  on  the  right  side.  At  the 
age  of  thirteen  he  was  in  a  state  of  profound  dementia;  at  nineteen  he  could  arti- 
culate a  few  sounds,  but  could  not  feed  himself  ;  his  right  leg  was  weak,  his  arm 
contracted.  He  died  in  his  twenty-second  year.  The  right  half  of  the  body  was 
thinner  and  smaller  than  the  left;  the  cranium  small,  well  formed,  very  thick; 
oedema  of  the  pia;  the  left  hemisphere  considerably  smaller  than  the  right.  The 
left  posterior  lobe  was  especially  small;  its  convolutions  as  thin  as  the  blade  of  a 
knife,  very  firm,  of  a  bright  yellow  color  externally,  internally  of  a  dull  white 
color;  the  left  middle  and  anterior  lobes  were  also  smaller  than  ordinary;  the  right 
posterior  lobe  was  likewise  a  little  diminished  and  shghtly  sclerotic;  the  optici 
were  indurated.  The  sclerosis  and  atrophy  of  the  brain  were  evidently  the  results 
of  an  encephalitic  process  consecutive  to  measles. 

Hypertrophy  of  the  brain  occurs  much  less  frequently  in  idiots  than 
do  the  various  alterations  which  we  have  enumerated;  it  is  impossible  to 
distinguish  it  during  life  from  hydrocephalus  distending  the  cranium,  as 
in  both  cases  the  head  is  large  and  the  ossification  imperfect,  and — 
whicn  is  interesting  in  many  ways — the  base  of  the  cranium  is  not  ex- 
tended, but  rather  shortened,  or  it  pi-esents  only  normal  proportions 
(Virchow). 

Baillarger  ('  Acad,  de  Med.,'  29  Jul.,  1856)  mentions  the  case  of  a  child  of  four 
years,  in  whom  the  brain  weighed  1,305  grammes  (or  more  than  the  adult  aver- 
age); and  another  case  of  a  child  ('  Gaz.  hebdomadaire,'  1859,  No.  6,  p.  93)  in  whom 
the  body  weighed  forty-six  pounds,  and  the  brain  1,160  grammes.  Bricquet, 
Delasiauve  have  recently  reported  analogous  cases. 

A  remarkable  appearance,  and  one  which  has  hitherto  received  very 


254  STATES    OF    MENTAL    WEAKNESS. 

little  attention,  is  the  unusiial  abundance  of  gray  substance  (in  the  ordi- 
nary localities)  which  has  been  remarked  by  various  observers  (Stalil, 
Eosch,  Niepce — seventh  and  ninth  autopsies)  in  the  brains  of  certain 
idiots,  the  amount  of  the  gray  substance  being  greater  than  that  of  the 
white.  Occasionally,  new  formations  of  gray  substance  are  found  in 
parts  where  in  the  normal  state  it  does  not  exist  (Virchow  found  this  in 
an  e^iileptic  idiot — I  once  saw  it  in  an  epileptic,  of  whose  mental  condi- 
tion there  was  no  information).  Finally,  the  reports  of  several  antopsies 
mention  the  interesting  fact  of  hypertrophy  of  the  pituitary  body  (Niepce, 
Bergmann).  We  may  here  very  properly  doubt  whether  these  were  cases 
of  true  hypertrophy,  or  of  some  other  morbid  change.  Niepce's  third 
and  sixth  autopsies  point  to  the  latter:  in  the  one  (third)  there  were  two 
small  concretions,  in  the  other  (sixth)  a  cavity  in  the  centre  (in  other 
cases,  too,  of  endemic  cretinism  the  pituitary  body  was  very  small). 
Examples  have  also  been  met  with  of  extraordinary  enlargement  of  the 
corpora  quadrigemina  (Niepce's  second  autopsy). 

§  161.  We  now  pass  from  the  anomalies  of  the  brain  itself  to  the  con- 
sideration of  those  of  the  cranium.  These  occur  very  frequently,  and  in 
great  variety,  in  idiots.  We  have  already  mentioned  this  circumstance 
when  speaking  of  the  consequences  of  defective  development  of  the  brain 
(§  158);  in  the  following  summary  we  shall  again  have  occasion  to  return 
in  part  to  this,  but  the  principal  subject  of  consideration  is  the  primary 
anomalies  of  the  cranium,  in  the  investigation  of  which  such  interesting 
discoveries  have  recently  been  made. 

It  does  not  lie  within  the  province  of  this  work  to  enter  into  minute  details 
upon  this  svibject.  The  reader  who  is  interested  in  this  study  is  recommended  to 
consult  the  original  works,  and  in  particular  to  examine  a  number  of  the  skulls 
which  may  be  found  in  any  pathological  museum.  See  Malacarne,  in  P.  Frank, 
'  Delectus  Opusc.  Med.'  vol.  vi.,  lie.  1789,  p.  241  ;  Ackermann,  'Ueber  die  Creti- 
nen  '  etc.,  Gotha,  1790  ;  J.  and  E.  Wenzel,  '  Ueber  den  Cretinismus,'  Wien,  1802  ; 
Stahl,  'Neue  Beitrage,'  etc.,  Erlangen,  1848,  2d  edition,  1851;  "Clinische  Stu- 
dien,"  etc.,  'Zeitschr.  f.  Psychiatrie,'  xi.,  1854,  p.  545;  ibid.,  xvi.,  1859,  p.  1  ; 
Virchow,  '  Wiirzb.  Verhandl.,'  1851,  1852,  1855,  1856,  and  '  Gesammelte  Abhandl.,' 
Frankfurt,  1856,  p.  891 ;  "  Untersuchungen  iiber  die  Entwickelung  des  Schadel- 
grundes,"  Berl,  1857 ;  "Ueber  Knochenwachsthum  und  Schadelformen."  Vir- 
chow's  ''Archiv,'  xiii.,  1858,  p.  323:  Luca,  '  Zur  Architectur  des  Menschen- 
schiidels,'  Frankf.,  1857;  Gratiolet,  "Mem.  sur  la  Microcephalie,"  'Journal  de 
Physiol.,'  ix.,  Jan.,  1860;  Lambl,  '  Aus  dem  Franz-Joseph-Kinderspitale,' etc., 
Prag,  1861. 

We  shall  not  occupy  ourselves  with  those  alterations  of  the  cranium 
which  are  at  present  of  little  interest  in  connection  with  idiocy,  such  as 
the  frequent  partial  attenuations,  and  the  still  more  frequent,  generally 
much  less  general,  thickenings  of  the  cranial  bones,  which  so  frequently 
constitute  the  sole  palpable  lesion  in  epilepsy,  and  the  connection  of 
which  with  that  disease,  and  also  with  idiocy,  is  in  many  cases  quite 
obscure;  nor  shall  we  consider,  further,  those  rare  cases  of  long-persist- 
ence, even  to  adult  life,'  of  the  fontanelles  and  such-like:  but  the  prin- 
cipal object  of  our  study  is  the  consideration  of  those  deviations  mthe 
development  and  growth  of  the  cranium  which  impart  to  it  abnormalities 
in  form.  We  must  here  consider,  especially— 1st,  anomalies  of  the  arch, 
and,  2d,  anomalies  of  the  base  of  the  cranium. 

Many  irregularities  in  the  development  of  the  arch  of  the  cranium 
are  produced  by  primary  anomalies  in  the  development  of  the  brain:  the 

'  Stahl  ('  Neue  Beitr.')  found  this  in  a  man  fifty  years  of  age. 


STATES    OF    MENTAL    WEAKNESS.  255 

ossification  of  the  cranial  bones  remains  behind,  owing  to  the  retarded 
growth  of  the  brain;  it  is  kept  back  owing  to  the  entire  brain  or  certain 
parts  of  it  remaining  small,  by  the  non-symmetrical  development  of  the 
brain,  etc.  Many  cases  of  simple  microcephalics  belong  to  this  form  of 
anomaly;  perhaps,  also,  many  unilateral  stenoses  of  the  cranium,  owing  to 
closure  of  the  sutures  witli  inequality  in  size  of  the  two  cerebral  hemi- 
spheres: in  this  case  the  ossification  of  the  sutures  is  not  the  cause  of  the 
malformation,  but  appears  ratlier  to  constitute  the  last  stage  of  the 
changes.  In  tliese  limitations  from  an  internal  cause,  from  the  contents 
of  the  ci'anium  owing  to  irregular  development  of  the  brain  there  are  fre- 
quently formed  a  number  of  closed  sutures — a  circumstance  of  great  im- 
portance in  the  determination  of  these  relations:  there  result  from  tliis, 
general  microcephalus,  or  partial  or  general  expansion  of  the  osseous 
arch  of  the  cranium. 

But,  evidently,  in  by  far  the  greater  number  of  cases  the  deviations 
in  form  of  the  cranial  arch  are  primary  and  independent  of  its  contents 
— of  the  development  of  tlie  brain.  These  depend,  especially,  upon 
interriiption  of  the  groivth  of  the  lones;  and  this,  again,  often  ajjpears  to 
be  owing  to  simple  deficiency  and  incompleteness  in  tlie  formation  of  bone 
substance,  it  may  be  from  constitutional  causes  acting  unfavorably  on  the 
■general  nutrition;  especially,  however,  and  most  frequently,  it  is  the 
result  of  an  idiopathic  morl)id,  apparently  inflammatory,  process  in  the 
sutures,  the  process  by  which  the  normal  growth  of  the  cranial  Isones 
proceeds,  and  which  terminates  in  occlusion  of  the  sutures.  Thus,  m 
whatever  way  a  suture  is  prematurely  ossified,  the  cranium  becomes  nar- 
rowed at  that  point,  because  the  growth  of  the  bones,  wliich  takes  jilace 
at  the  suture,  is  arrested,  and,  of  course,  always  in  a  direction  perpen- 
dicular to  the  suture.  This  limiting  of  one  j)art  may,  wlien  it  is  con- 
siderable, extend  its  infiuence  far  beyond  the  part:  thus,  for  example, 
very  early  synostosis  of  the  arch  of  the  cranium  also  affects  the  growth  of 
the  basis  cranii,  shortens  or  narrows  it. 

In  many  cases,  there  merely  remains  a  contraction  of  the  skull  owing 
to  the  arrested  growth  of  the  bones,  and  the  cranium  is  simply  deformed. 
In  other  cases,  however,  corresponding  dilatations  are  formed  in  other 
parts  of  the  cranium,  because  the  brain  grows  towards  the  side  where  it 
meets  least  resistance,  because  there  the  sutures  are  more  distended  by 
the  growing  brain,  and  consequently  present  more  points  of  ossification, 
and  i^erhaps  there  is  a  tendency  even  to  exuberant  growth.  These  so- 
called  compensations  correct  the  contractions  in  the  cranial  cavity,  but 
they  very  often  produce  even  greater  deformity  of  the  skull  than  was 
caused  by  the  original  contraction.  When  stenosis  is  once  established, 
all  depends  upon  these  compensations  for  the  normal  development  of  the 
brain,  and,  therefore,  of  the  mental  faculties.  These  compensations 
themselves  appear  principally  to  depend  upon  an  active  growth  of  the 
brain,  and,  consequently,  in  these  changes  in  form  we  have  not  solely  to 
do  with  purely  mechanical  relations,  but  with  a  far  more  intimate  nutri- 
tive relation  connected  with  the  condition,  with  the  jiower  or  weakness 
of  the  general  physical  nutrition.  In  all  considerable  ossifications  of  the 
sutures,  the  compensations  are  seldom  sufiicient  for  the  complete  develop- 
ment of  the  brain,  and,  therefore,  even  with  them  the  cavity  of  the 
cranium  is  generally  too  small. 

A  special  and  rare  kind  of  compensation  (incomplete)  consists  in  the  formation 
of  the  so-called  encephalitic  protuherances  (Lambl) — protuberances  on  the  skull, 
especially  in  the  neighborhood  of  the  sutures  and  fontanelles.     These  always 


256  STATES    OF    MENTAL    WEAKNESS. 

appear  to  be  connected  with  internal  hydrocephalus,  and  are  produced  by  the 
pressure  of  the  compressed  parts  of  the  brain  ;  they  may  even  proceed  to  the  for- 
mation of  greater  or  smaller  deficiencies  in  the  osseous  cranium. 

The  deformities  produced  by  these  stenoses  may  be  referred  to  seyeral 
principal  types.  When  all  or  nearly  all  the  sutures  of  the  arch  of  the 
cranium  become  closed  at  a  very  early  stage,  there  results  simple  uniform 
mkvoceplialus:  if  the  base  of  the  cranium  becomes  also  ossified,  or  should 
no  compensation  be  formed  there,  the  entire  cranium,  though  small,  is 
properly  proportioned;  but  the  growth  of  the  brain  is  also  uniformly  and 
most  profoundly  disturbed.  Should,  on  the  contrary,  a  great  compensa- 
tion be  made  by  the  ossification  of  the  basis  cranii  being  rendered  un- 
usually slow,  and  consequently  a  much  greater  expansion  of  it  rendered 
possible,  there  appears  to  originate  from  this  a  special  type  of  physiog- 
nomical and  physical  development,  and  also  of  intellectual  life,  which  we 
shall  afterwards  describe  more  minutely  under  the  name  of  the  Aztec 
type.  Merely  partial  occlusion  of  the  sutures  of  the  arch  of  the  cranium 
determines  the  following  principal  forms: — Too  narrow  crania  (i.  e., 
when  the  transverse  diameter  is  shortened)  are  caused  principally  by 
early  ossificartion  of  the  sagittal  suture;  more  rarely,  and  ratiier  with  con- 
traction of  the  frontal  than  the  parietal  region,  by  ossification  of  the 
spheno-frontal  suture.  Ossification  of  both  sides  of  the  suture  between 
the  occipital  bone  and  the  mastoid  portion  of  the  temporal  bone  may,  as 
I  found  in  the  cranium  of  a  semi-cretin  girl  of  nineteen  years,  consider- 
ably diminish  the  whole  inferior  part  of  the  cranium,  situated  between 
the  two  mastoid  processes,  and  consequently  the  space  destined  for  the 
cerebellum.  In  these  crania,  compensation  takes  place  in  the  antero- 
posterior diameter,  by  enlargement  of  the  frontal  region  and  protuberance 
of  the  occiput.  Too  short  crania  are  caused,  behind,  by  ossification  of 
the  lambdoidal  suture  (the  highest  degree  of  absence  of  the  posterior 
portion  of  the  cranium  causes  the  rare  ape-like  from  of  the  so-called 
mask),  and  here  compensation  often  takes  place  by  development  of  the  re- 
gion of  the  anterior  fontanelle  (conical  or  sugar-loaf  heads);  in  front,  the 
shortening  is  caused  by  extended  ossification  of  the  frontal  with  the. 
parietal  bones,  the  cranium  being,  at  the  same  time,  very  low.  Other  too 
loiu  crania  are  caused  by  ossification  of  the  wings  of  the  sphenoid  with 
the  frontal  bone  and  squamous  portion  of  the  temporal  bone.  Finally, 
the  unsymmetrical  obliquely  narrowed  crania  are  caused  by  unilateral  os- 
sification, anteriorly  through  ossification  of  one-half  of  the  coronal  su- 
ture, posteriorly  through  ossification  of  one-half  of  the  lambdoidal  suture; 
compensation  takes  place  by  increased  extension  towards  the  opposite 
sides.  All  these  stenoses  which  we  have  enumerated,  as  they  occur  at  a. 
very  early  period,  involve  to  the  development  of  the  corresponding  por- 
tions of  the  brain:  for  example,  unilateral  stenoses  are  apt  to  cause  short- 
ening of  one  of  the  cerebral  hemispheres,  etc.  These  hindrances  to  the 
development  of  the  brain  are  very  rarely  fully  corrected  by  the  so-called 
compensations,  and  are  seldom  without  serious  consequences. 

It  appears,  morever,  that  dis-symmetry  (and  deformity  generally)  maybe 
caused  not  only  by  partial  stenoses,  but  also  by  local  expansion  ;  naniely,  by  the 
immoderate  development  of  ossa  Wormiana  :  in  particular,  a  special  form  ot 
elongated  cranium  appears  to  be  produced  by  the  plentiful  formation  of  Wor- 
mian bones.  1  According  to  Lambl  (1.  c,  p.  26),  scolioses  of  the  cranium  origi- 
nate also  in  rickety  children  through  displacement,  owing  to  softness  ot  the 
bones  and  long  continuance  of  the  sutures  :  finally,  there  also  appear  to  be  scoli- 

1  Virchow,  '  Gesammelte  Abhandlungen,'  p.  902. 


STATES    OF    MENTAL    WEAKNESS.  257 

oses  which  cannot  be  referred  to  any  of  the  causes  which  we  have  mentioned,  but 
can  only  be  attributed  to  an  original  disproportion  in  the  energy  of  the  growth  of 
the  bones  at  a  particular  part. 

If  the  original  primary  obstacles  to  the  development  of  the  brain  have 
a  very  great  influence  upon  the  development  and  form  of  the  arch  of  the 
cranium,  influences  of  tiiis  kind  upon  tlie  development  of  the  bones  of 
the  base  of  the  cranium  are,  as  yet,  almost  unknown,  and  all  the  clianges 
which  occur  in  this  part  of  the  cranium,  when  not  compensatory  or  con- 
secutive to  changes  in  the  arch  of  the  cranium,'  are  in  the  present  state 
of  science  to  be  considered  as  primary  and  indej^eudent  anomalies  due  to 
disorders  in  nutrition  of  the  bone  and  cartilage  itself .  These  changes  are 
almost  entirely  due  to  premature  ossification  of  the  base.  As  the  growth 
of  the  bones  in  the  arch  of  the  cranium  depends  on  the  persistence  of  the 
sutures,  the  growth  of  the  bones  of  the  base  depends  upon  the  persistence  of 
the  cartilages;  and  the  prmiature  ossification  of  these  cartilaginous  surfaces 
arrests  the  longitudinal  development  of  bones  which  enter  into  the  forma- 
tion of  the  base  of  the  cranium,  which  must,  of  course,  produce  shortening 
of  the  base.  More  rarely,  the  ossification  of  the  cartilaginous  disc  between 
the  primitive  anterior  and  posterior  portions  of  the  sphenoid  bone  pro- 
duces this  result:  this  is  ordinarily  completed  at  birth,  or  at  least  soon  after 
it;  it  is  rather  the  ossification  of  the  synchondrosis  between  the  sphenoid  and 
the  basilar  portion,  which  in  the  normal  state  does  not  occur  till  the  fif- 
teenth year,  and  sometimes  not  till  the  twentieth  year  and  even  later: 
thus,  the  base  of  the  cranium  has,  in  the  normal  state,  fully  fifteen  years 
to  grow  in  the  antero-posterior  direction. — This  shortening  of  the  base 
of  the  cranium  by  ossification  is  followed  by  very  serious  consequences. 
Should  it  occur  very  early,  it  imparts  to  the  basis  cranii  a  form  which  is 
only  normal  at  the  middle  of  intrauterine  life;  namely,  a  great  curvature 
upwards  of  the  base  of  the  cranium,  a  small  angle  at  the  point  of  union 
between  the  sphenoid  and  tlie  basilar  portion,  a  steep  clivus:  further, 
this  shortening  causes  malformation  of  the  face  (cretin  physignomy), 
which  is  characterized  by  prominence  of  the  ridge  of  the  nose  (cocked-up 
nose) ;  the  roots  of  the  nose  are  deeply  set  and  very  broad,  the  eyes  widely 
apart,  the  orbits  large  but  shallow,  the  cheek-bones  high  and  prominent 
(Prognathismus).  With  limitation  of  the  development  of  the  base  of  the 
cranium  are  connected  the  further  results  of  a  shallow  and  transverse 
position  of  the  sphenoid  bone,  and  of  a  consequent  lessening  of  the  great 
wings,  and  of  the  central  cavity  connected  with  them.  There  is  thus  pro- 
duced through  this — together  with  a  probable  unfavorable  influence  upon 
the  development  of  the  pons  Varolii  and  medulla  oblongata  from  the  abnor- 
mally formed  clivus — arrest  of  development  of  the  anterior  and  middle 
parts  of  the  brain.  Actual  microcej)halus  may  now  exist;  more  frequently 
this  is  not  the  case,  and  thereareproduced  various  compensations,  which, 
however,  are  not  complete,  probably  on  account  of  the  deficient  develop- 
ment of  the  brain.  These  compensations  are  produced  partly  by  growth 
,of  tlie  cranium  upwards  (conical  heads),  partly  by  elongation  of  the  arch 
of  the  cranium  with  persistence  of  the  frontal  suture,  or,  finally,  by  mod- 
erate dilatation  of  the  superior  and  posterior  parts  of  the  head. 

The  tribasilar  synostosis  forms  the  anatomical  foundation,  and,  as  it  appears, 
the  sole  point  of  origin  of  07ie  special  form  of  cretinism  whicli  is  specially  repre- 


'  Thus,  for  example,  may  synostosis  of  the  superior  cranial  sutures,  especially 
of  the  coronal  suture,  have  a  direct  influence  in  shortening  the  base  of  the 
cranium. 

17 


258  STATES    OF    MENTAL    AVEAKNESS. 

sented  in  Alpine  cretinism.     Several  of  the  older  observei-s  had  ah-eady  arrived  at 
the  perfectly  correct  conclusion  that  the  fundamental  lesion  in  this  form  is  in  the 
base  of  the  cranium,  and  had  very  nearly  come  to  tlie  correct  idea  upon  tlie  sub- 
iect.   Ackermann  said  (1790),  I.  c,  p.  33,  '•  It  is  solely  on  the  lower  part  of- the  basis 
cranii  that  the  abnormal  change  exists  which  essentially  constitutes  cretmism  ;  " 
and  in  page  119  he  says,  "  It  is  this  slight  alteration  in  form  of  the  occipital  and 
sphenoid  bones  (he  chiefly  refers  to  the  too  horizontal  position  of  the  occipital 
bone)  which  constitutes  cretinism."    The  Brothers  Wenzel  express  themselves  in 
quite  analogous  terms,  1.  c.  pp.  54-59  :  "In  cretins  the  surface  of  the  base  of  the 
cranium  is  shortened,  as  if  compressed  in  the  antero-posterior  diameter  ;  the  fun- 
damental changes  chiefly  involve  the  base  of  the  cranium,"  etc.  ;  and  further  on, 
p.  206,  "the  anomalies  of  cretinism  which  sometimes  show  themselves  even  in  the 
newly  born  child,  are  all  of  a  nature  such  as  might  lead  us  to  suppose  that  there 
exists  a  high  degree  of  deformity  in  the  basis  cranii."    Autenrieth  also  expresses 
similar  sentiments  (quoted  by  Wenzel,  1.  c,  p.  218).     This  part  of  the  inquiry, 
however,  was  altogether  neglected  in  the  subsequent  investigations  regarding 
cretinism.     Stahl  revived  it  (1848).     The  actual  state  of  matters  in  this  funda- 
mental deformity  of  the  basis  cranii  was,  however,  for  the  flrst  tune  clearly  eluci- 
dated by  the  investigations  of  Virchow.     This  observer  has  also  shown  that  com- 
plete synostosis  of  the  two  parts  of  the  sphenoid  bone  and  the  basilar  portion  may 
even  occur  during  ftetal  life,  in  which  case  the  newly  born  child  will  present,  m 
a  marked  degree,  the  physiognomical  peculiarities  of  cretinism.     It  is  self-evident 
that  basilar  synostosis,  with  shortening  of  the  base  of  the  cranium,  not  only  does 
not  lie  at  the  foundation  of  all  forms  of  cretinism  (idiocy  with  physical  deformity), 
but  even  is  not  always  present  in  endemic  Alpine  cretinism.   This,  however,  does 
not  oppose  the  theory  advanced  by  Virchow— it  rather  confirms  it,  owing  to  the 
circumstance  that  we  occasionally  find  in  individuals  with  endemic  cretinism  (a,s 
also  in  certain  healthy  persons)  the  sphenoid  and  the  basilar  portion  not  yet  ossi- 
fied after  the  age  of  twenty  (Niepce,  1.  c,  ii.,  p.  118,  6th  section  ;'  Stahl,  '  Neue 
Beitriige,' p.  70  ;  '  Zeitschr.  f.  Psych.,'  Bd.  xvi.,  p.  368).     The  basilar  synostosis 
o-ives  rise  to  a  special,  but  very  frequent  form  of  cretinism,  possessing  the  peculiar 
phvsiognomical  expression,  and— to  which  the  small  size  of  body,  the  frequent 
complete  dwarfishness,  points— the  cartUaginous  epiphyses  of  the  long  bones  of 
the  extremities  seem  also  to  experience  a  similar  arrest  of  development  from 
premature  ossification  :  therefore  in  these  cases  we  ought  not  to  attribute  the 
stunted  growth  of  the  body,  as  we  do  in  unilateral  atrophy  or  in  many  niicro- 
cephals  to  the  affectien  of  the  brain,  but  to  a  constitutional  malady  with  prema- 
ture ossification  of  the  cartilages— to  an  affection  which,  in  many  respects,  is 
diametrically  opposed  to  rickets.     True  rickets  has  never  been  observed  to  pass 
into  cretinism;  a  circumstance  of  great  importance  in  the  treatment  of  these  con- 
ditions. 

The  types  of  cerebral  abnormalities  which  correspond  to  the  various 
deformities  of  the  cranium  which  have  been  described  are  as  yet  very  in- 
completely known,  and  would  form  an  interesting  subject  of  investigation 
to  those  who  have  the  opportunity. 

§  162.  On  reviewing  what  has  been  said  regarding  the  anatomical 
foundations  of  idiocy  and  cretinism,  we  find  that  in  a  great  number  of 
cases  there  exist  cerebral  and  cranial  anomalies  which  must  necessarily 
act  unfavorably  on  the  development  of  the  brain.  The  two  series  of  phe- 
nomena are  very  different  in  their  nature;  they  cannot  be  referred  to  one 
type,  nor  to  a  single  fundamental  process.  We  must  also  carefully  guard 
a'crainst  recognizing  in  the  special  nature  of  an  anomaly  which  is  presented 
to  us— for  example,  in  hydrocephalus,  or  in  a  deficiency  m  the  commis- 
sural system  of  the  brain,— the  immediate  anatomical  cause  of  the 
i.sychical  disorder  in  question— of  the  idiocy.  This  anomaly,  or  this  de- 
fect, may  perhaps  have  no  influence  in  regard  to  the  special  psychical 
disorder,  and  the  latter  depends  upon  the  mode  in  which  the  existing, 

'  It  is  worthy  of  remark,  that  in  these  cases  the  penetrating  body  was  greatly 
hypertropliied,  and  contained  a  cavity  in  the  centre  :  while  in  Virchow  s  case  ot 
a  newly  born  cretin  with  complete  synostosis,  the  pituitarj-  body  was  very  smaU— 
almost  atrophied. 


STATKS    OF    MENTAL    WEAKNESS.  '     259 

apparently  quite  uormal,  parts  perform  their  functions.  But  those 
palpable  and  evident  changes  clearly  demonstrate,  on  the  one  hand,  that 
at  all  events  the  brain  was  diseased  or  defective;  and  on  the  other  hand, 
we  must  remember  wliat  the  elements  are  which  gradually  contribute  to 
the  development  of  the  intelligence  of  the  child — that  the  elaboration  of 
the  sensorial  impressions  and  the  formation  of  the  internal  impulses  of 
movement  constitute  the  special  basis  of  the  mental  development — that 
disorders  in  the  function  of  those  parts  of  the  brain  which,  perhaps,  have 
little  to  do  with  the  more  elevated  mental  processes,  but  have  great  influ- 
ence upon  the  development  of  the  functions  of  the  brain  which  relate  to 
sensation  and  movement,  may  withdraw  what  is  essential  to  the  develop- 
ment of  the  mind  by  severing  it  from  the  healthy  roots  through  which  it 
is  developed  from  the  sensitive  faculty. 

Regarding  the  mechanism  by  which  each  of  these  cerebral  changes  are 
produced,  we  know  much  which  serves  to  explain  their  origin  (intra- 
uterine cerebral  inflammations,  other  foital  diseases,  synostoses,  etc.);  in 
regard  to  the  cases  of  deficient  development,  there  is  a  circumstance 
which  seems  to  me  to  deserve  more  consideration  than  has  yet  been  ac- 
corded to  it,  namely,  that  of  abnormal  narrowness  of  the  cerebral  arteries, 
which  may  be  eitlier  a  primary  defect  in  development,  or  the  result  of  an 
abnormal  state  of  the  bones  with  contraction  of  the  foramina  (con- 
traction of  the  carotid  canal  from  abnormal  state  of  the  sphenoid 
bone?). 

This  contraction  of  the  arteries  was  very  prominent  in  the  anterior  SylArian 
fissure  and  on  the  basilar  portion  in  several  of  Niepce's  cases  :  in  tliree  cases  of 
endemic  cretinism,  also,  the  vertebral  and  basilar  arteries  were  very  sniall. 
(Report  of  the  Sardinian  Commission,  p.  204.)  I  found  both  carotid  canals,  but 
especially  that  of  the  right  side,  very  narrow  in  the  cranium  of  an  idiotic  girl 
-with  poverty  of  the  brain  and  inequality  of  the  hemispheres.  May  not  premature 
thickening  of  the  bones  of  the  basis  cranii  have  this  effect  ?  May  not  this  factor 
play  an  important  part  in  compensating  for  deformities  of  the  base  which  have 
been  brought  about  by  the  pressure  of  a  brain  growing  with  morbid  activity  ? — 
and,  again,  where  this  growth  is  rendered  less  active  by  narrowing  of  the  arte- 
ries, will  not  less  compensation  be  required  ? 

§  163.  As  all  the  various  diseases  of  the  brain  and  its  membranes 
which  occur  during  intra-uterine  life  and  in  childhood  agree  in  this,  that 
they  impede  the  complete  development  of  the  brain,  therefore  all  the 
mental  disorders  of  childhood  must  have  the  same  result,  namely,  that  of 
impeding  the  development  of  the  mind.  This  disordered  development 
manifests  itself  in  anomalies  of  all  the  mental  faculties,  and  these  are  far 
from  being  the  same  in  every  case  of  idiocy:  therefore,  each  case  ought  to 
be  specially  investigated,  in  order  to  discover  in  what  manner  the  mental 
mechanism  is  disturbed.  Here,  therefore,  we  must  content  ourselves 
with  a  general  consideration  of  the  disorders  of  the  mind. 

Anoinalies  of  percej)tion. — In  severe  cases,  the  sensorial  impressions 
produce  very  few  ideas:  these  are  so  fleeting  and  so  superficial,  that  they 
soon  again  disappear,  and  the  process  of  abstraction  does  not  proceed,  so 
that  they  continue  isolated — as  entirely  or  half  sensorial  ideas.  There  is 
likewise  a  deficiency  in  the  production  of  ideas,  as  well  as  in  their — 
which  occurs  involuntarily  in  health — movement  and  elaboration, — that 
combination  with  other  ideas  which  render  them  a  part  of  our  inner  con- 
sciousness; there  is  no  regular  subject  of  thought  which  might  powerfully 
grasp  the  new  ideas,  determine  the  impulses  of  will,  form  opinions — 
which,  in  a  word,  could  constitute  an  ego.  We  observe,  also,  loss  of  the 
powers  of  attention  and  reflection;  they  have  no  memory,  no  mental 


260  STATKS    OF    MENTAL    WEAKNESS. 

spontaniety:  in  extreme  cases  we  can  discover  no  germ  of  individuality 
which  might  be  compared  to  the  healthy  ego;  no  trace  of  a  mental  person- 
ality. 

These  defects  in  concrete  cases  are  not  only  manifested  in  various  ways,  but 
the  phenomena  themselves  may  also  be  altgether  different:  in  the  one,  tiiat  per- 
haps is  destroyed  which  in  another  never  existed,  in  the  one  the  sensorial  element 
may  be  at  fault;  in  the  other  the  abstractive  element,  etc.  There  are  many  idiots 
in  whom  we  can  discover  actually  no  symptoms  of  mental  life — neglected  children 
of  nature,  completely  unconscious  of  the  world  and  of  time,  who  exist  in  a  state 
of  profound  dreain;  are  completely  strange  to  all  tliat  goes  on  around  them,  and 
show  no  other  spontaneous  «ign  of  life  than  devouring  the  food  which  is  placed 
in  their  mouths.  The  animal  perceives  the  external  world;  it  is  complete  in  its 
special  organization;  it  is  capable  of  expressing  its  impressions,  its  sensations  and 
desires,  with  the  means  of  gratifying  them.  In  this  respect  these  poor  idiots 
stand  far  below  the  healthy  brute,  but  withouton  that  account — which  very  curi- 
ously is  possessed  even  by  tliem  as  a  leading  characteristic — being  deprived  of 
humanity.  In  many  others  the  clear  consciousness  of  a  special  personality, 
thought,  and  almost  the  very  attempt  to  speak,  even  by  gestures,  are  wanting; 
but  a  greater  degree  of  perception  of  the  world  penetrates  their  state  of  dream, 
and  they  present  at  least  a  commencement  towards  finding  their  position  in  it. 
An  idiot  of  this  kind  does  not,  for  example,  wait  till  some  one  removes  the  finger 
which  he  has  just  bitten  from  his  mouth,  but  can  accomplish  this  himself.  They 
recognize  their  attendants,  the  preparations  for  meals,  etc. ;  they  feel  a  desire  for 
muscular  motion,  which  is  performed  in  the  most  uniform  manner;'  gradually 
acquire  a  mechanical  knowledge  of  certain  words,  orders,  etc.,  which  they  exe- 
cute automatically  (they  do  this,  however,  in  a  manner  quite  different  from  that 
of  healthy  children,  without  regarding  the  speaker  or  manifesting  any  expression 
of  countenance).  From  these  types  of  extreme  degradation  there  are  numerous 
gradual  transitions  to  somewhat  better  states,  in  which  the  external  world 
becomes  more  and  more  recognized  and  elaborated  in  an  elementary  fashion. 
From  this  a  small  store  of  knowledge  is  accumulated,  and  the  possession  of  an  ego 
capable  of  simple  functions  is  rendered  possible.  It  is  a  remarkable  fact  that 
sometimes  the  excitation  of  an  acute  disease  -  calls  forth  manifestations  of  mind 
and  capacities  which,  in  the  ordinary  state,  lie  latent.  This  permits  the  conclu- 
sion that  in  certain  idiots  there  is  more  received  into  the  mind  and  there  elabo- 
rated than  one  might  be  led  to  suppose,  which,  however,  cannot  be  expressed  by 
them,  although  it  leaves  its  traces  behind. 

A  leading  characteristic  of  all  severe  cases  of  idiocy  is  the  complete 
absence  of  speech,  so  that  not  even  the  attempt  is  ever  made,  or  speech 
so  very  imperfect  as  to  be  called  idiotic  dumbness  (not  dependent  upon 
want  of  hearing).  It  depends  upon  want  of  ideas,  or  want  of  _  reflex 
action  from  the  perceptive  to  the  motory  faculties  to  the  mechanism  of 
speech:  the  first  have  nothing  to  say,  the  second ''have  no  desire  to 
speak."  The  idiot  who  does  not  speak,  has,  likewise,  no  internal  idea  of 
speech,  and,  therefore,  is  deficient  in  the  most  essential  element  in  the 
mechanism  of  abstraction. 

The  relations  of  speech  are  so  interwoven  with  the  whole  process  of  mental 
development,  and  so  necessary  to  education  and  intellectual  advancement,  that 
the  classification  of  idiots  according  to  their  capability  of  speaking  (generally  into 
three  degrees)  is  one  of  the  best  that  can  be  established. 

According  as  these  idiotic  states  become  less  profound,  more  ideas 
may  be  formed  and  combined  to  simple  judgments   and    conclusions. 

'  I  know  a  boy,  fourteen  years  of  age,  a  little  microcephaUc,  but  otherwise 
well  formed,  who,  every  day  all  day  long,  pushes  out  and  in  a  drawer,  and  rattles 
two  keys.  . ,.         , 

^  See  Niepce,  '  Comptes  rendus,'  37,  1853,  No.  16:  Case  of  an  idiot  who  was 
seized  with  hydrophobia.  Usually  he  could  not  articulate  more  than  a  few 
words,  and  now  he  spoke  fluently  about  things  which  happened  years  ago,  and  to 
which  he  at  the  time  appeared  to  pay  not  the  slightest  attention. 


STATES    OF    MENTAL    WEAKNESS.  261 

But  that  prompt,  involuntary  blending  of  the  ideas,  by  wliich  the  process 
of  abstraction  is  rendered  easy,  not  a  laborious  act  forced  by  frequent 
repetition,  is  entirely  wanting;  there  is  no  lively  mental  reaction,  strong 
impressions  are  required  to  excite  it:  therefore,  the  indifference  and  lack 
of  interest  in  the  affairs  of  the  external  world  manifested  by  these  persons, 
their  perpetual  immobility  to  sensorial  impressions,  and  their  extremely 
limited  spontaneity.  On  closer  investigation,  they  manifest  differences 
in  their  intelligence  which,  in  many,  become  actual  peculiarities  which 
are  not  amenable  to  the  ordinary  means  of  education. 

With  the  growing  receptivity  dependent  upon  increasing  capability  of 
function  of  the  apparatus  of  thought  in  the  brain,  the  conceptions  and 
ideas  become  more  numerous,  the  speech  more  perfect,  and,  in  the  end, 
even  reading  and  writing  are  possible;  there  is  increasing  intercourse 
with  the  external  world.  But  to  accomplish  several  mental  processes  at 
the  same  time  or  in  rapid  succession  is  impossible:  therefore,  the  under- 
standing is  in  general  slower,  the  judgment  uncertain  and  diffident;  the 
sphere  of  comprehension  can  only  be  caught  at  its  borders,  and  this  even 
under  foreign  guidance;  memory  is  the  only  accessible  way  to  education; 
the  individual  in  a  very  simple  sphere  of  life  is  satisfied  with  moderate 
demands,  rational  thought  and  action,  and  makes  himself  useful  by  per- 
forming that  sort  of  work  which  exercises  the  imitative  rather  than  the 
initiative  faculties. 

The  remarkable  one-sided  aptitudes  and  talents  occasionally  displayed 
in  the  slighter  degrees  of  idiocy  are  rather  of  a  semi-conscious  instinctive 
character,  and  may  be  compared  to  the  instincts  of  animals.  In  these 
cases,  certain  series  of  ideas  rapidly  and  easily  develop  themselves,  and 
with  them  appear  the  means  for  their  correct  and  evident  manifestation 
— mechanical,  musical,  arithmetical  talent,  memory  for  words,  signs, 
etc.  We  never  find  these  special  aptitudes  in  cases  of  idiocy  occurring 
accidentally,  occurring  in  once  healthy  children  in  consequence  of  cere- 
bral disease  in  early  youth,  but  only  where  the  disease  is  hereditary  or 
endemic. 

In  the  beautiful  asylum  for  idiots  at  Eai-lswood,  near  London,  I  saw  a  young 
person  who  had,  quite  unaided,  built  a  very  pretty  and  large  model  of  a  war-ship; 
he  was  of  limited  mental  capacity,  and  had,  in  particular,  no  idea  of  numhers. 
We  frequently  see  persons  in  profound  idiocy  execute  (purely  mechanical)  curi- 
ous works  of  design  and  painting.  Morel  (' Etudes  Clin.,'  i.,  p.  49)  recites  the 
remarkable  case  of  a  speechless  idiot  who  had  a  special  gift  of  playing  on  the 
dnim;  his  grandfather  had  been  drum-major  and  his  father  drummer  in  a  regi- 
ment; his  brother  had  always  had  a  desire  (which,  however,  was  not  gratified)  to 
become  a  drummer.  The  remart;able  memory  for  places  also  exhibited  by 
certain  idiots  of  low  mental  capacity  is  very  analogous  to  these  special  talents. 

It  would  not  be  altogether  correct  to  judge  of  the  severity  of  the  cerebral 
lesion  by  the  degree  of  mental  weakness;  a  great  deal  here  depends  upon  the 
locality,  upon  the  social  medium  in  which  the  child  lives.  Children  who  have 
been  weU  cared  for,  with  whom  persons  have  taken  soma  trouble,  whose  minds 
have  been  properly  directed,  behave  very  differently  from  those  whose  education 
has  been  neglected,  and  whose  minds  have  been  excited,  although  the  cerebral 
disease  may  have  been  quite  as  severe.  We  observe  also  that,  in  the  cretin  dis- 
tricts, those  who  roam  about,  who  go  about  the  villages  begging,  etc.,  are  far 
more  intelligent  than  those  kept  constantly  in  the  house.  All  education  is,  of 
course,  useless  in  the  very  lowest  degrees  of  idiocy. 

§  164.  Anomalies  of  self-consciousnes,  the  desires,  and  the  will. — In 
general,  the  state  of  these  faculties  corresponds  exactly  to  the  degree  of 
weakness  of  the  intellect:  nevertheless,  even  in  severe  cases,  the  naturally 
existing  feelings  and  dispositions  proceeding  from  the  body,  with  the  ex- 


262  BTATE8    OF    MENTAL     WEAKNESS. 

citations  proceeding  from  it  toward  the  emotions  and  the  will,  always 
present  a  great  field  of  psychical  activity.  In  the  most  profound  cases  of 
idiocy,  the  joyful  and  painful  emotions  (anger,  etc.),  are  entirely  con- 
nected with  bodily  sensations,  or  they  appear  to  originate  immediately,  en- 
tirely Avithout  motive,  through  obscure  changes  in  the  state  of  the  brain 
and  nervous  system.  The  habitual  nature  of  these  emotions,  which  has 
become  persistent,  gives  to  the  lowest  grades  of  these  a  something  which 
may  be  termed  their  individual  disposition,  their  character.  In  this  re- 
spect we  may,  in  severe- cases,  establish  extreme  types:  on  the  one  hand, 
those  grim,  sometimes  truly  fearful,  almost  ferocious,  and  often  wild  and 
fearful  idiots;  and,  on  the  other  hand,  those  who,  with  absoluj^e  want 
of  intellect,  constantly  exhibit  a  joyful  and  gay  disposition,— who,  with 
always— about  nothing— laughing  features  and  good-humored  eyes,  bear 
the  expression  of  good-nature  and  complacency.  In  profound  idiocy  the 
efforts  and  determmations  are  principally  set  i-n  motion  by  the  instincts, 
above  all  by  the  instinct  for  food;  most  of  these  acts  have  the  character 
of  half-conscious  reflex  actions;  certain  simple  ideas  which  have  become 
persistent— for  example,  pleasure  in  playing  with  little  strips  of  paper, 
etc. — can  again  excite  volition.  It  is  self-evident  that  the  acts  of  these 
idiots  do  not  proceed  from  free  choice,  not  from  actual  volition;  there 
exists  in  them  no  ego,  or  at  all  events  merely  a  trace  of  it,  and  in  many 
cases— but  not  belonging  to  the  most  degraded  class— we  are  frequently 
led,  on  observing  their  instinctive  acts,  to  ask  ourselves,  Is  there  any- 
thing in  them  which  represents  a  will?  and  who  or  what  can  will  in 
them  ? 

In  many  idiots  of  the  lowest  class,  eating  is  the  only  thing  which  seems  to 
move  their  soul:  the  most  debased  manifest  this  desire  by  restlessness,  gruntmg 
noises,  etc.,  those  a  little  higher  in  the  scale  move  their  hands  and  lips  ui  a  cer- 
tain manner,  or  weep  tin  some  food  is  given  them;  they  "wmtr'to  be  fed.  lu 
the  lowest  forms  we  also  occasionally  see  rapid  changes  of  humor,  occurrmg 
without  external  motive;  for  example,  at  one  time  the  expression  of  fear,  or  wish 
to  go  away,  or  sudden  aversion  to  an  accustomed  amusement,  or  they  become 
an«-ry  at  it.  This  anger  is  often  very  violently  expressed  by  scratching,  throw- 
ing the  arms  about,  biting,  etc  ,  even  to  actual  mania.  Those  capricious  emo- 
tions observed  m  certain  individuals  are  quite  inexplicable,  as,  for  example,  the 
appearance  of  all  the  signs  of  jovful  excitement  whenever  they  see  a  piece  of 
paper  or  the  manifestation  of  tlie  most  tender  regard  towards  some  particular 
child,  while  they  appear  to  take  no  notice  of  anything  else;  a  good-humored  idiot, 
when  taken  ill,  commencing  to  scold  himself,  to  knock  his  head  against  the  waU, 
etc. 

In  the  slighter  cases,  inconsistency  and  dulness  of  the  emotions,  and 
weakness  of  will,  are  also  general  charac^ristics:  the  disposition,  there- 
fore, very  much  depends  upon  the  surroundings,  and  the  treatment  to 
which  the  individual  is  subjected.  Under  good  treatment,  for  example,  in 
the  idiot  asylums,  most  of  these  children  are  good-natured,  obedient, 
happy,  and  sociable;  when  maltreated,  they  become  embittered  and  malici- 
ous; in  some  there  habitually  exists  a  melancholic  or  more  excited  frame 
of  mind.  In  the  localities  where  cretinism  is  endemic,  we  seldom  observe 
any  agreeable  traits  of  character  in  these  idiots.  The  higher  degrees  are 
characterized  by  great  dulness  of  sentiment;  they  are  unsociable  amongst 
themselves  and  repugnant  to  each  other.  The  semi-cretins,  whose  good- 
nature "has  its  origin  neither  in  the  head  nor  in  the  heart,  but  in  the 
stomach"  (MaSei),  are  still  incapable  of  any  real  affection,  or  even  at- 
tachment, or,  indeed,  of  any  human  feeling;  they  are  rude  egotists, 
whose  desire  for  idleness  can  only  be  overcome  by  force,  or  by  the  pros- 
pect of  enjoyment. 


STATES    OF    MENTAL    WEAKNESS.  263 

§  165.  TJie  anomalies  m  the  senses  and  in  the  movements  observed  in 
a,  great  number  of  idiots  are  extremely  important.  In  severe  cases  these, 
especially  the  latter,  are  always  present,  although  in  very  different  de- 
grees; they  generally  depend  immediately  upon  the  morbid  state  of  the 
central  nervous  apparatus.  As  a  rule,  the  sense  of  sight  is  the  best;  and 
when  it  is  affected,  it  appears  to  depend  more  upon  affections  of  the  eye 
itself,  which  is  affected  by  amblyopia,  than  upon  the  state  of  the  brain : 
strabismus,  in  all  its  degrees,  is  frequent.  Hearing  is  frequently  dull; 
frequently,  however,  it  is  very  difficult  to  distinguish  whether  actual 
deafness  exists,  or  only  comi^lete  want  of  attention.  Smell  and  taste  are 
generally  imperfect  (the  olfactory  bulbs  are  often  imperfectly  developed): 
we  seldom  see  idiots  smell  things  like  animals,  and  rejecting  what  does 
not  please  them;  many  appear  to  be  alike  indifferent  to  all  impressions  of 
smell,  and  likewise  of  taste,  so  that  they  put  the  most  unclean  things 
into  their  mouths — eat  nettles,  excrement,  etc.  Others  exhibit  a  spe- 
cial aversion  towards  certain  kinds  of  food,  as  beef,  and  will  eat  only 
milk  and  bread,  and  such  like.  The  cutaneous  sensibility  is  very  dull; 
in  many,  very  little  pain  can  be  excited  in  the  skin,  and  examples  occur 
of  extended  actual  anaesthesia,.  This  does  not  apply  to  the  severe  cases: 
in  many  semi-idiots,  or  those  in  whom  development  has  been  simply 
arrested,  sensibility  to  cold  and  to. injury  does  not  exist;  in  these  cases 
the  sense  of  hearing  is  always  weak. 

The  anomalies  of  movement  consist  in  convulsions,  contractions,  and 
paralyses.  The  convulsions  are  sometimes  local — for  example,  in  the 
toes,  in  an  arm  or  leg;  sometimes  more  general,  when  they  not  unfre- 
qucntly  resemble  chorea.  But  the  most  serious  of  all  are  the  epilepti- 
form convulsions,  Avhich  constitute  an  extremely  fatal  compliction,  and 
one  which  is  very  unfavorable  in  a  prognostic  point  of  view,  and  ex- 
tremely frequent  in  severe  cases.  Frequently,  the  acute  cerebral  affec- 
tions (§  365)  which  occur  about  the  period  of  dentition,  or  somewhat 
later,  constitute  the  point  of  origin  of  epilepsy,  as  of  idiocy  itself;  there 
are  cases,  always  of  the  most  serious  description,  where  the  epileptic 
convulsions  are  for  years  daily  repeated.  Evidently,  the  epilepsy  is  gen- 
erally a  symptom  of  the  disease  of  the  central  nervous  apparatus,  which 
determines  the  deficient  mental  development,  and  then  apj)ears  simulta- 
neously with  or  not  till  long  after  the  commencement  of  the  idiocy  (some- 
times not  till  the  period  of  puberty);  but  certainly  there  are  also  cases 
where  a  different  relation  exists  between  the  two  series  of  symptoms — 
where  the  epilepsy  is  entirely  to  be  considered  the  primary  and  chief  dis- 
ease, and  the  mental  weakness  and  the  result  of  the  violent  commo- 
tion and  exhaustion  of  the  cerebral  functions  caused  by  the  frequent  at- 
tacks, just  as  we  occasionally  see  in  the  adults,  especially  after  the  first 
rapidly  repeated  epileptic  attacks,  extreme  dulness  and  general  derange- 
ment of  all  the  mental  functions,  which  lasts  for  several  days.'  The  con- 
tractions are  more  frequently  partial — of  the  toes,  of  the  sterno-mastoid 
muscles,  spasmodic  club-foot,  etc. ;  sometimes  they  are  more  general,  as, 
for  example,  of  the  knee-joint,  so  that  the  heel  is  kept  firmly  pressed 

'  I  have  already  expressed  this  opinion  in  the  '  Twelfth  Annual  Report  of  the 
Asylum  at  Mariaburg,'  Tubingen,  1859.  Should  we  succeed  by  very  early  and 
appropriate  treatment  in  removing  the  epilepsy,  w^e  may  also  hope  to  improve  the 
idiocy;  very  soon,  however,  these  cases  become  incurable  when  the  epileptic 
attacks  continue,  and  are  frequently  repeated.  I  shall  communicate  the  result  of 
my  numerous  observations  of  this  disease  during  the  last  few  years  in  another 
place. 


264  STATES    OF    MENTAL    AVEAKNESS. 

against  the  nates.  Paralytic  conditions  are  much  more  frequent.  Many 
of  the  most  degraded  idiots  can  neither  stand  nor  walk;  the  lower  ex- 
tremities are  relaxed,  stiff,  or  atrophied,  owing  to  which  slight  convul- 
sive movements  often  take  place  in  them.  Frequently,  there  is  a  condi- 
tion of  muscular  weakness  with  premature  fatty  atrophy;  the  limbs 
remain  small,  have  a  purple  hue,  and  are  always  cold,  as  has  been  observ- 
ed in  the  so-called  "paralysis  of  children"  (Heine).  From  this  there  are 
all  possible  kinds  of  transitions  to  more  partial  forms  of  paralysis,  paraly- 
tic club-foot,  etc.  Many  of  these  paralyses  are  in  severe  cases  referable 
to  the  cerebral  affection  itself;  others,  as  it  appears,  to  a  coexisting 
disease  (atrophy)  of  the  spinal  marrow;  the  electric  contractility  is  also 
much  diminished  (Zuradelli,  1860).  In  the  slighter  cases  of  idiocy — in 
the  semi-cretins,  for  exaraiile— we  frequently  observe  not  only  the  gene- 
ral feebleness  of  bod}^  the  uncertainty  of  gait,  the  helpless  use  of  the 
hands,  but  also  many  indications  of  spasmodic  and  paralytic  muscular 
affections,  imperfect  development  or  atrophy  of  certain  groups  of  mus~ 
cles,  or  of  a  complete  half  of  the  body. 

It  is  interesting  to  observe  the  automatic  movements,  and  the  entire 
outward  demeanor,  particularly  in  the  severe  cases.  In  these  feeble 
and,  often,  so  peculiar  manifestations  of  a  perfectly  stunted  intelligence, 
there  exists  something  which  provokes  us  to  problematic  conjecture;  but 
who  can  determine  what  shall  be  the  answer?  In  many  of  these  children, 
continuous  rocking,  swinging  movements  are  observed,  accompanied  by 
monotonous  singing,  murmuring  tones  which  form  a  sort  of  cadence; 
others  continually  shake  their  head,  constantly  suck  their  fingers,  fre- 
quently clap  their  hands,  beat  violently  against  the  wall,  puff  and  blow 
with  their  mouths,  etc.  A  very  peculiar  circumstance  which  is  some- 
times observed,  is  the  rapid  carrying  of  the  hand  to  one  of  the  eyelids, 
whereby  the  eye  becomes  rubbed,  compressed,  or  even  disjilaced  (will  they 
see  double?).  The  expression  of  countenance  and  whole  bearing  of  these 
degraded  idiot  children  manifest  complete  nullity  of  the  intelligence, 
with  unprovoked  alternations  of  superficial  emotions  (laughing  and  weep- 
ing), movements  like  the  undulations  caused  by  a  gentle  breeze  upon, 
the  calm  sea. 

In  many  of  the  most  severe  cases  of  idiocy,  the  sexual  functions 
are  entirely  absent;  the  genital  organs  are  frequently  small  and  stunted; 
the  menses  are  long  in  appearing,  not  until  after  the  twentieth  year,  or 
perhaps  they  do  not  appear  at  all:  nevertheless,  cases  of  extreme  idiocy 
sometimes  occur,  in  which  the  menses  appear  at  the  proper  time  and 
continue  regular.  Pernicious  sexual  habits  are,  even  in  severe  cases  of 
idiocy,  quite  as  frequent  as  they  are  destructive  to  what  remains  of  the 
mental  functions.  In  tlie  moderate  cases  of  idiocv,  the  sexual  func- 
tions  also  present  great  differences;  but,  as  a  rule,  they  are  more 
generally  diminished  than  increased.  Conception,  it  is  true,  sometimes 
occurs  amongst  semicretins;  but  all  that  has  been  said  regarding  the 
exaggerated  sexual  instincts  of  idiots  is  false,  and  only  based  upon  the 
shameless  demeanor  of  certain  individuals  belonging  to  the  class  of  semi- 
cretins. 

A  thick,  fleshy  tongue,  which  sometimes  causes  the  incisor  teeth  to 
protrude — copious  salivary  secretion — unequal,  irregular,  and  carious 
teeth,  are  frequently  found  in  idiots  of  every  degree. 

§  166.  Hitherto,  in  describing  the  symptomatology  of  idiocy  merely, 
the  most  general  traits  drawn  from  a  great  number  of  cases  of  all  degrees 
have  been  depicted;  we  shall  now  mention  a  few  more  points,  to  direct 


STATES    OF    MENTAL    WEAJKJS'ESS.  265 

ns  in  the  midst  of  the  ver}-  various  symptoms  presented  in  individual 
cases. 

In  all  idiotic  states,  two  fundamental  forms  may  be  easily  distin- 
guished, which  in  their  extreme  degrees  differ  widely  from  each  other, 
but,  of  course,  in  many  moderate  cases  are  not  so  distinctly  pronounced, 
viz.,  the  apathetic  (dull,  torpid),  and  the  excited  (versatile,  agitated).  The 
profound  idiots  of  the  first  category  have  frequently  an  awkward,  clumsy, 
and  disproportioned  body,  and  repulsive,  old-looking  features;'  the  dul- 
ness  of  their  movements,  their  passiveness — their  stupid,  monotonous, 
unexcitahle  demeanor — cause  them  in  many  cases  to  appear  as  if  they 
were  in  a  state  resembling  sleep;  many  have  a  brooding,  melancholy  look, 
while  others  have  only  the  expression  of  utter  indifference,  w^ant  of 
thought  and  of  mind.  Those  of  the  second  category  are  really  much 
deformed,  but  generally  remain  far  behind  their  years;  sometimes  they 
are  proportionate  and  even  well  formed,  and  of  fine  but  delicate  appear- 
ance. They  are  restless  in  their  movements,  quick,  irritable,  rapidly 
change  their  impressions;  but  they  are  extremely  absent,  and  in  the  higher 
gi'ades  utterly  incapable  of  fixing  anything  on  their  mind.  It  is  often 
astonishing,  when  we  see  the  happy  expression  and  apparent  activity  of 
these  children,  to  find  that  they  are  utterly  incapable  of  speech  and  void 
of  understanding.  In  many  cases  the  behavior  is  often  so  excitable  and 
turbulent,  moving  tlie  body,  jumping  abottt,  gesticulating,  laughing, 
weeping,  crying,  all  day  long,  that  it  actually  appears  to  pass  into  mania 
(see  p.  103).  In  this,  the  excited  form,  extremes  are  much  more  rare 
than  in  the  apathetic  form,  and  the  slighter  cases  are  more  capable  of 
improvement  than  the  corresponding  degrees  of  torpidity. 

Besides  these  two  principal  groups,  we  find  ourselves  constrained,  on  glancing 
over  numerous  cases  of  idiocy,  still  further  to  distinguish  certain  well-marked 
varieties  upon  the  basis  of  the  external  characteristics,  and  with  regard  to  the 
mental  peculiarities. 

1st.  Children  perfectly  well-proportioned  and  well-developed  for  their  age, 
apparently  in  good  health — if  no  disease  exist  in  other  organs — with  a  pleasant 
expression  of  countenance,  and,  as  a  rule,  microcephalic.  The  mental  develop- 
ment may  remain  at  the  lowest  grade,  or  have  advanced  to  various  degrees ;  they 
are  generally  moderately  versatile,  but  sometimes  apathetic,  with  lifeless,  rather 
automatic  movements,  sometimes  with  weakness  of  the  lower  extremities. 
These  cases  are  not  only  always  sporadic  and  extremely  rare,  but  they  seem  to  be  the 
result  o£  altogether  accidental  cerebral  affections,  occurring  in  previously  healthy 
and  well-developed  children  without  any  hereditary  disposition,  without  any 
degenerative  element,  without  miasmatic  influences,  etc.  In  these  cases,  the 
physical  development  proceeds  properly,  in  spite  of  the  cerebral  affection. 

'2d.  Children  in  whom  the  physical  and  mental  development  is  simply  much 
retarded.  The  interesting  extreme  cases  of  this  kind  present  a  complete  arrest 
of  development  at  an  early  period  of  life;  for  example,  at  the  age  of  from  four 
to  six,  with  aU  the  peculiarities  of  that  age,  without  considerable  deformity  or 
degeneration.  These  cases  are  diametrically  opposite  to  the  other  remarkable 
extreme  of  an  extraordinarily  rapid  bodily  development  (where,  in  certain  cases, 
children  of  four  to  five  years,  and  even  earlier,  have  already  attained  to  a  con- 
siderable degree  of  physical  development,  and  presented  the  symptoms  of 
puberty).  It  appears  admissible,  at  least  in  certain  cases  of  this  kind,  to  compare 
them  with  those  arrests  of  development  which,  in  atrophj-  of  one  of  the  cerebral 
hemispheres,  involves  the  opposite  half  of  the  body,  but  here,  where  both  hemi- 
spheres are  affected,  involves  both  sides:  but  these  cases  would  require  to  be 
studied  anew,  of  which  they  are  well  worthy. 

Dancel  (1837  and  1843,  '  Acad,  des  Sciences ')  has  communicated  the  case  of  a 
young  woman,  aet.  24,  whose  development  proceeded  normally  up  to  the  age  of 
three  and  a  half  years,  when  it  was  suddenly  arrested.  At  the  age  of  eighteen 
and  a  half,  she  was  94  centimetres  in  height;  her  mental  state  was  that  of  a  child 
of  three  and  a  half  years.  At  twenty-one,  she  grew  a  little  and  attained  the  height 
of  96  centimetres;  from  that  time  forth,  her  condition  remained  stationary. 


266  STATES    OF    MKJMTAL    WKAKNE88. 

Baillarger  presented  before  the  Academy  of  Medicine  (26th  May,  1857)  a  young 
woman,  set.  27,  who  had  the  intelligence  and  inclinations  of  a  child  of  four 
years:  she  is  about  three  feet  high,  the  body  very  fat;  the  second  dentition  com- 
menced when  she  was  eighteen,  and  at  twenty-seven  was  not  completed. 
Menstruation  had  not  yet  set  in. 

I  know  of  another  remarkable  case  of  this  kind,  in  which,  in  consequence  of 
a  blow  on  the  head  during  childhood,  the  development  which  had  till  then  been 
normal  was  completely  arrested. 

If,  however,  the  extreme  cases  of  this  kind  are  very  rare,  the  moderate  cases 
are,  on  the  contrary,  extremely  common.  They  constitute  the  numerous  class 
of  children  stopped  in  their  growth  (enfants  arrieres),  whose  peculiarity  consists 
in  the  circumstance  that  without  special  deformity,  with  no  symptoms  of  cere- 
bral disease,  the  whole  mental  and  bodily  development  proceeds  very  slowly. 
Those  individuals  are  all  small;  their  sexual  system— with  certain  exceptions— is 
late  in  developing,  and  sometimes  is  never  developed  at  all;  at  the  age  of  twenty 
they  resemble  children  of  ten  or  twelve  years;  they  may  be  well-proportioned, 
but  more  frequently  they  present  all  sorts  of  defects — distorted  countenances, 
clumsy  features,  the  root  of  the  nose  impressed,  strabismus,  dulness  of  heaiiug. 
Mentally  they  are  distinguished  from  true  idiots  by  the  greater  capability  of 
development,  which  only  proceeds  much  more  slowly  than  in  other  children; 
they  learn  to  walk,  to  speak,  to  write,  but  at  a  much  later  period  than  in  health; 
they  are  incapable  of  occupying  themselves  with  several  subjects  at  the  same 
time,  and  consequently  of  making  comparisons;  they  are  accessible,  and  capable 
of  improvement  through  the  memory  and  imitative  faculties,  but  only  make 
progress  when  they  are  assiduously  and  specially  treated,  schooled,  and  in- 
structed. It  is  those  cases  which  are  proudly  exhibited  as  examples  of  "re- 
coveries" in  idiot  asylums.  Should  they,  at  the  same  time,  happen  to  be  epileptic, 
if  they  are  addicted  to  onanism,  all  mental  impulse  is  wanting;  they  become 
gradually  more  degraded,  and  at  last  completely  idiotic. 

In  this  very  numerous  class  we  again  find  many,  physically  and  mentally, 
peculiar  types;  as,  for  example,  children  who  remain  so  small  that  they  are 
actually  dwarfish,  with  round  forms,  slow,  easy  movements,  an  expression  of 
great  benevolence  and  good-humor;  these  little  fellows  have  sometimes  some- 
thing extremely  droll  and  humorous  in  their  manners  and  actions:  they,  how- 
ever, though  extremely  good-natured,  have  many  childish  peculiarities,  and  are 
only  capable  of  education  if  carefully  treated,  have  affection  for  their  instructors, 
and  give  them  no  trouble.  An  extremely  dangerous  class  is  formed  by  those 
weak-minded  children  with  instinctive  (congenital)  evil  desires  to  mischief, 
cruelty,  theft,  drunkenness,  etc.,  which  sometimes  nothing  can  suppress.  These 
individuals,  when  their  intelligence  is  such  as  to  permit  them  to  remain  out  of  an 
asylum,  afterwards  furnish  a  numerous  contingent  to  our  prisons  and  houses  of 
correction;  their  state  is  frequently  evidently  hereditary,  and  their  habits  are  by 
no  means  identical  with  the  evil  desires  which  are  developed  in  children  through 
the  example  of  their  seniors. 

3d.  The  sinosto-basilar  form;  cretinism  in  the  proper  sense  of  the  term.  The 
extreme  degrees  of  this  form  are  to  be  found  only  in  the  localities  where  cretinism 
is  endemic,  and  particularly  in  the  mountainous  districts,  and  even  in  these 
countries  it  appears  to  be  less  common  than  it  used  to  be;  even  the  moderate 
degrees  present  the  deformity  and  ugliness  characteristic  of  cretmism.  Generally, 
the  head  is  disproportionately  large;  the  features  old-looking;  the  body  small, 
thick-set,  and  often  cliild-like;  the  lips  thick,  the  eyelids  puffy,  the  nose  large  and 
deeply  impressed  at  its  base;  the  body  is  often  swollen  and  puffy- looking,  owing 
to  hypertrophy  of  the  skin  and  subcutaneous  cellular  tissue;  usually  also  goitre  is 
present:  in  the  higher  degrees  they  scarcely  resemble  human  creatures.  Their 
mental  life  has  altogether  the  character  of  apathy  and  torpor;  they  are  deaf  and 
dumb,  and  sometimes  inclined  to  outbreaks  of  savage  anger.  In  opposition  to 
the  theory  that  these  states  are  actual  monstrosities  (Rosch,  Virchow),  we  can 
always  show  that  the  malady  frequently  does  not  commence  till  after  birth,  and 
that  in  its  moderate  degrees  it  is  capable  of  some  degree  of  improvement 
(see  §  169).  ,     , 

4th.  A  form  in  every  respect  quite  the  opposite  of  the  foregoing  is  that  which 
has  been  termed  the  Aztec  type.^  These  Aztecs  are  microcephals,  whose  bodies 
remain  small  but  well-proportioned,  slender,  sometimes  even  elegant  in  form; 


•  Very   good  examples  of   this  form   were  some  years  ago  exhibited  as  the 
reputed  remnant  of  the  extinct  American  Aztec  people:  therefore  the  name. 


STATES    OF    MENTAL    WEAKNESS.  267 

the  base  of  the  nose  is  generally  high,  so  that  the  forehead  passes  straight  into  it. 
These  little  beings  are  extremely  lively,  their  movements  sprightly  and  well  co- 
ordinated; they  are  happy,  easily  excited,  inquisitive,  but  very  capricious,  little 
capable  of  attention,  and  of  weak  intellect,  although  many  of  them  can  speaJc 
correctly.  The  very  interesting  investigation  of  Gratiolet  (three  cases,  1.  c.) 
showed  a  very  small  cranium,  the  bones  thick,  and  synostosis  of  the  arch:  the 
basis  cranii,  on  the  contrary,  was  very  slightly  ossified;  the  basilar  portion 
almost  quite  cartilaginous;  the  petrous  portion  and  ethmoid  bone  were  rather 
larger  than  normal;  the  space  for  the  cerebellum  was  enormous  in  all  directions. 
The  bram  of  these  microcephals  may  present  fewer  convolutions  than  that  of  the 
ourang-outang  or  chimpanzee;  the  cerebellum  is  very  large,  as  is  also  the  spinal 
cord  and  medulla  oblongata.  The  organs  of  sense  and  their  nerves  are  well- 
developed;  the  state  of  the  convolutions  shows  that  the  condition  existed  before 
birth.  The  exuberant  development  of  the  more  spinal  portions  of  the  brain,  in 
contradistinction  to  the  hemispheres  corresponding  to  the  compensatory  dilatation 
of  the  basis  cranii  (see  §  161),  corresponds  to  the  peculiar  anomaly  of  the  functions 
which  constitutes  a  direct  opposition  to  that  presented  by  the  form  with  diminu- 
tion of  the  basis  cranii.  Here  also  extreme  examples  are  rare,  but  in  most  idiot 
institutions  examples  may  be  found  which  represent  the  moderate  degrees  of  this 
type:  I,  myself,  prefer  to  call  it  the  "bird-hke  form;"  and  the  small,  low  or 
short  head,  aquiline  nose,  and  lively  movable  eyes,  strongly  remind  us  of  the 
physiognomy  of  birds. 

5th.  Certain  idiots,  in  their  physiognomy,  habits,  and  demeanor,  resemble  in 
a  still  more  specific  manner  certain  species  of  animals.  Some  strongly  reseml)le 
apes  (well-marked  microcephalus),  others  forcibly  remind  us  of  swine.  The  fol- 
lowing case  observed  by  Pinel  affords  another  rare  example  belonging  to  this 
category: — An  idiotic  girl,  eleven  years  of  age,  resembled,  by  the  form  of  her 
head,  by  her  desires  and  capacities,  a  sheep.  She  manifested  aversion  towards 
animal  food,  ate  only  vegetables  and  drank  nothing  but  water;  her  whole  speech 
consisted  in  he,  ma  taiite,  whereby  she  showed  her  attachment  to  her  nurse: 
she  also,  like  a  sheep,  laid  her  head  on  the  abdomen  of  her  nurse;  when  fightino- 
with  other  children,  she  butted  them  as  a  sheep  does;  when  wishing  to  fall 
asleep,  she  curled  herself  on  the  floor.  Her  back,  shoulders,  and  loins  were  clothed 
with  a  kind  of  soft  black  hair,  one  to  two  inches  long,  which  much  resembled 
wool. 

Further  observations  in  asylums  will  afford  material  for  the  discovery  of  other 
types,  the  arrangement  of  forms,  and,  finally,  for  referring  them  to  characteristic 
fundamental  disorders.  The- opposite  types — synosto-basUar  and  Aztec — are 
specially  worthy  of  further  anatomical  investigation. 

§  167.  As  to  the  course  of  the  yarious  cerebral  affections  which  lie  at 
the  foundation  of  the  different  forms  of  idiocy,  it  is  self-evident  that  very- 
little  can  be  said  upon  the  subject  generally.     The  process  which  has 
caused  the  arrest  of  development  may  have  already  in  great  part  disap- 
peared at  birth;  in  which  case  all  mental  processes  are  from  the  com- 
mencement very  feeble,  speech  is  not  developed,  etc.,  and  they  all  remain 
stationary.     Or  the  cerebral  disease  (which  perhaps  may  be  hereditary) 
does  not  commence  until  mental  development  is  actually  begun,   and  it 
may  be  either  an  acute  or  a  chronic  insidious  affection.     The  mental 
development  ceases  to  progress,  and  even  generally  recedes;  speech  is 
often  forgotten,  and  the  expression  of  stupidity  and  mental  poverty  be- 
comes dominant      It  is  especially  in  hydrocephalic  cliildren  that  acute 
attacks  of  cerebral  excitation  of  greater  or  less  severity,  with  symptoms 
of  cerebral  congestion,  are  frequently  repeated:  after  each  of  these  the 
obtusion  and  apathj^  become  more  profound  and  persistent.     Epileptic 
convulsions  exercise  in  every  case  a  prejudical  influence  upon  the  psychi- 
cal symptoms.     The  cerebral  disease  in  idiots  is  generally  of  a  nature 
such  as  by  itself  causes  death  very  slowly  (for  example,  high  degrees  of 
hydrocephalus,  perhaps  also  of  atrophy  of  the  brain),  or  gives  rise  to 
intercurrent  fatal  processes  in  the  cranial  cavity  (death  by  meningitis, 
acute  effusions,  etc.).     But  even  should  this  not  be  the  case,  still  many 


268  STATES    OF    MENTAL    WEAKNESS. 

idiots  die  during  cliildiiood:  this  may  be  because  many  injurious  influ- 
ences act  more  strongly  upon  them  than  upon  healthy  children,  or  because 
their  power  of  resisting  disease  is  less.  It  is,  therefore,  rare  to  see  idiots 
attain  a  great  age;  they  are  most  frequently  seen  in  countries  where  cre- 
tinism is  endemic,  where  examples  may  be  met  with  of  cretins  of  sixty 
or  seventy  years  of  age.  The  reader  need  scarcely  be  reminded  how  much 
depends,  in  all  such  questions,  upon  the  external  relations,  care,  etc. 

§  168.  Improvement  takes  place  in  many  cases  of  idiocy.  It  is  rarely 
that,  under  the  influence  of  a  favorable  change  in  the  entire  physical 
health,  the  child  becomes  lively  and  studious  within  a  short  time,  and 
continues  to  make  rapid  progress.  More  frequently,  improvement  con- 
sists merely  of  a  more  free  and  more- regular  employment  of  the  existing 
fragments  or  remnants  of  intelligence,  be  they  greater  or  less;  and  this 
result  can  only  be  attained  very  gradually,  in  the  course  of  many  years. 
The  first  condition  necessary  to  all  improvement  is  the  complete  cessation 
of  the  cerebral  disease  which  occasioned  the  idiocy. 

By  cure  of  idiocy,  must  be  understood  the  complete  removal  of  the 
cerebral  disease  which  hinders  the  mental  development;  a  process  where- 
by cultivation  of  the  intellect  by  education  and  instruction  would  be 
rendered  possible.  Kecovery  in  this  sense  can  only  be  considered  possible 
in  certain  cases,  viz.,  when  the  cerebral  affection  is  simply  functional 
(§  156),  or  when,  at  the  commencement  of  a  palpable  cerebral  disease  in 
childhood,  the  morbid  process  can  still  be  arrested:  in  certain  chronic 
processes  (for  example,  due  to  the  influence  of  syphilis  or  other  chronic 
constitutional  anomaly),  this  period  is  sometimes  of  long  duration. 

As  a  rule,  however,  the  morbid  processes  have  entirely  or  almost  en- 
tirely run  their  course  before  the  idiocy  is  recognized.  Then  we  have  to 
deal  with  residues  and  consecutive  states;  and  these  offer  the  greatest  re- 
sistance to  spontaneous  or  artificial  recovery,  inasmuch  as,  owing  to  them, 
the  development  of  the  brain,  its  normal  growth  within  a  given  period,  is 
interrupted  or  impaired.  In  all  these,  constituting  the  immense  major- 
ity of  cases,  the  utmost  that  can  be  attained  is  successful  improvement 
of  what  remains  of  the  psychical  faculties,  intellectual,  sensitive,  and 
motory;  the  highest  aim  of  this  improvement  is  a  certain  capability  of 
self-direction  in  life,  the  possession  of  a  few  correct  moral  ideas,  and  a 
certain  degree  of  practical  usefulness,  without,  on  that  account,  all  traces 
of  the  idiotic  condition  being  effaced.  Here,  therefore,  we  can  only  speak 
of  improvement:  this,  however,  may  be  of  extreme  advantage  to  the  indi- 
viduals themselves,  as  well  as  to  their  relatives,  and  the  existence  of  idiot 
asylums  must  be  considered  an  actual  necessity. 

From  what  has  been  said,  it  is  evident  that  the  treatment  of  idiocy 
must  consist,  on  the  one  hand,  of  therapeutical  (hygienic  and  medicinal) 
treatment,  and,  on  the  other,  of  education,  not  only  of  the  mind,  but 
also,  and  principally,  of  the  organs  of  sense  and  of  movement,  awakening 
and  developing  the  faculty  of  speech,  practice  in  the  correct  performance 
the  functions  of  ordinary  life. 

By  far  the  best  rules  on  this  subject  are  to  be  found  in  Seguin's  '  Traitement 
des  Idiots,'  Paris,  1846.  We  may  also  refer  to  Kern,  '  Zeitschrift  f.  Psychiatric,' 
xii.,  1855,  p.  531;  Damerow,  ibid.,  xv.,  1858,  p.  499;  Guggenbiihl  (together  with 
many  other  works),  '  Zeitschrift  der  k.  k.  Ges.  des  Aerzte  in  Wien,'  1860,  No.  6. 

B.  Endemic  Cretinism. 

The  following  works,  besides  those  mentioned  in  §  161,  are  the  most  important 
on  the  subject  of  Cretinism  in  the  strict  sense  of  the  term :— Fodere,  '  Essai  sur  le 


STATES    OF    MENTAL    WEAKNESS.  269 

Goitre  et  le  Cretinisme,"  Turin,  1792;  Ipliofen,  '  Der  Cretinismus,'  Dresden,  1817; 
Mafifei  und  Rosch,  '  Unters.  iiber  Cretinismus,'  2  Bde.,  Erlangen,  1844;  Meyer- 
Ahreus,  'Hiisers  Archiv,'  1845,  p.  360;  Prager  '  Vierteljahrschrift,'  Bd.  xlii., 
1854,  p.  99;  Behrend,  'Journal  fiir  Kinderkrankheiten,'  1846,  Juli;  'Rapport  de 
la  Commission  creee  par  S.  M.  le  Roi  de  Sardaigne,'  etc.,  Turin,  1848  (indis- 
pensable for  the  study  of  cretinism);  Ferrus,  '  Acad,  de  Medecine,'  10th  and  31st 
December,  1851,  and  Discussion;  Rosch,  '  Beobacht,  tiber  den  Cretinismus,' 
Tiibingen,  1850-1852;  Niepce,  'Tr.  du  Goitre  et  du  Cretinisme,  2  Bde.,  Paris, 
1851,  1852;  Billet,  'Ann.  Med.  Psychol.,'  1854,  pp.  339,  362,  530;  1855,  p,  41;  Morel, 
ibid.,  p.  334;  "West,  'Journal  f.  Kinderkrankheiten,'  1854,  xii.,  7,  8;  Kostl,  'Der 
endemische  Cretinismus,'  etc.,  Wien,  1855;  Fabre,  'Traite  du  Goitre  et  du 
Cretinisme,'  Par.,  1857;  Morel,  '  Traitedes  Degenerescences,'  etc.,  Par.,  1857,  and 
his  two  later  works  ('  Clinique,'  1853,  and  '  Traite,  1860);  Erlenmeyer,'  Archiv  der 
D.  Gesellschaft  f.  Psychiatric,'  i.,  1858,  pp.  13,  97;  Theile,  '  Ueber  Cretinismus;' 
Schmidt's  '  Jalirb.,'  1860,  No.  7;  Zillner,  "  Ueber  Idiotie,"  in  '  Nova  Acta  Caesar. 
Ac.  Leop.-Ca.,'  xix.,  1860. 

§  169.  The  distinction  between  sporadic  and  endemic  idiocy  depends, 
in  the  first  place,  upon  a  simply  quantitative  relation,  the  greater  or  les- 
ser frequency  of  the  affection  in  a  given  population.  But  in  this  distinc- 
tion there  are  contained  still  other  legitimate  differences  in  quality.  The 
causes  which  render  idiocy  so  frequent  in  a  particular  locality  are  gene- 
rally (not  unexceptioually)  peculiar;  indeed,  sometimes  specific  (mias- 
•  matic),  and  excite  peculiar  diseases  Avhich  lead  to  idiocy.  Sporadic 
idiocy  may  be  owing  to  any  kind  of  infantile  cerebral  disorder;  endemic 
idiocy,  likewise,  does  not  always  depend  upon  the  same  anatomical 
changes,  but  rather  upon  a  certain  class  of  changes  which  in  particular 
primarily  affect  the  skull  more  than  the  brain.  These  latter  affections 
are  much  more  associated  with  general  physical  deformity — a  deformity 
which  is  altogether  special  to  cretins,  and  associated  with  the  disease  of 
the  thyroid  gland.  There  are  also  certain  qualitative  differences  between 
endemic  and  sporadic  idiocy  which  cannot  be  disputed,  inasmuch  as  the 
well-marked  forms  of  the  cretin  districts  which  are  very  common,  or  were 
so  till  very  recently  in  those  localities,  are  never  met  with  sporadically 
in  the  same  form. 

I  can  readily  understand  how  observers,  in  those  countries  where  cretinism  is 
endemic,  could  be  led  to  deny  the  existence  of  any  distinction  between  endemic 
and  sporadic  idiocy.  They  dwell  in  the  midst  of  a  population  who  bear  gener- 
ally a  trace  (more  or  less  evident)  of  cretinism,  and  they  are  not  in  a  position  to 
observe  cases  of  accidental  cerebral  disease  which  may  occasion  idiocy  without 
any  physical  deformity,  where,  as  we  have  already  several  times  remarked,  well- 
developed  and  beautiful  children  present  the  complete  intellectual  nullity  of 
profound  idiocy.  As  it  is  very  rarely  that  the  well-marked  deformity  peculiar  to 
profound  cretinism  occurs  sporadically,  it  is  also  seldom  that  we  see  such  sporadic 
cases  occur  in  the  form  of  endemic  idiocy:  such  cases  may,  perhaps,  occasionally 
occur  in  the  cretin  districts  (for  example,  cases  of  accidental  encephalitis  or  of  cere- 
bral defect),  but  certainly  tliese  are,  in  the  first  place,  to  be  distinguished  from 
the  principal  prevailing  diseases  which  lie  at  the  foundation  of  the  endeniic 
cretimsm.  And  it  may,  moreover,  be  asked — special  observations  do  not  appear 
ever  to  have  been  made  on  this  point — whether  these  accidental  diseases,  in  a 
generally  infected  population,  do  not  assume  the  form  of  the  ijrevailing  degener- 
ation. In  England,  idiocy  is  not  rare — in  many  parts  it  may  even  be  said  to  be 
frequent — but  those  unsightly  deformities  (Alpine  form)  are  never  seen;  there  is, 
therefore,  a  great  difference  between  frequent  idiocy  and  "cretinism."  Virchow 
also  says,  endemic  idiocy  is  not  cretinism;  he,  however,  considers  thedifference 
to  be  altogether  etiological ;  that  which  originates  from  conditions  of  the  soil,  of 
the  locality,  is  cretinism;  that  which  results  from  social  conditions  is  idiocy. 
Unfortunately,  he  does  not  tell  us  how  w^e  may  certainly  distinguish  all  which 
originates  froni  territorial  and  all  which  arises  from  social  conditions.  Besides, 
what  may  not  be  comprehended  under  the  term  ' '  social  conditions  ?  " 

§  170.  Regarding  the  2Jropagatio?i  of  idiocy  as  an  endemic  disease  we 


270  STATES    OF    MENTAL    WEAKNESS. 

have  here  a  very  little  to  say. '  In  the  first  place,  we  have  the  important 
fact  that  endemic  cretinism  is  always  accompanied  by  endemic  goitre,  and 
in  such  a  manner  that  we  are,  in  some  degree,  authorized  to  recognize 
in  both  tlie  eifects  of  one  and  the  same  morbid  cause,  which  only  acts 
more  strongly  in  a  certain  series  of  cases,  and  in  some  its  effects  are 
more  widely  diffused  (affection  of  the  cranial  and  of  tlie  bones  gene- 
rally) than  in  others  (simple  affection  of  thyroid  gland).  Thus  it  is  that 
the  great  majority  of  cretins  have  a  large  goitre,  which  is  sometimes  con- 
genital and  sometimes  developed  after  birth,  and  which  in  general  as- 
sumes a  rapid  growth  about  the  period  of  puberty.  It  is  rare,  indeed,  to 
find  no  trace  of  goitre;  even  the  semi-cretins  and  a  large  proportion  of 
the  healthy  population  of  these  districts  are  affected  by  it.  The  great 
centres  of  these  two  diseases  are  in  all  parts  of  the  world  the  great  moun- 
tain chains  and  their  connections — in  Europe  the  Alps,  in  Asia  the  Hima- 
layas, in  America  the  Cordilleras.  The  sea-coast  is  altogether  exempt 
from  these  maladies;  in  flat  inland  countries  or  in  mountainous  districts 
•  of  the  second  or  third  class,  they  are  very  unequally  distributed,  and  we 
cannot,  ^s  yet,  state  with  certainty  the  common  cause  of  these  differences. 

In  Europe  the  countries  in  which  cretinism  is  most  frequent  are. 
Savoy;  many  parts  of  Switzerland,  particularly  tlie  cantons  of  Valais, 
Grison,  Uri,  Vaud,  Argow,  etc. ;  more  towards  the  east,  Salzburg,  Styria,* 
Tyrol,  Carinthia,  Upper  Austria:  next  in  order  come  several  regions  in 
the  Pyrenees,  the  mountains  of  Auvergne,  certain  parts  of  the  valley  of 
the  Rhine,  in  the  neighborhood  of  Strasburg  (above  all,  in  plains  wliich 
are  often  inundated);  the  Island  of  Mederworth  (which  is  frequently  in- 
undated), then  lower  and  middle  Franconia,  many  parts  of  Wiirtemberg 
and  the  grand  Duchy  of  Baden.  These  are  the  localities  which,  at  the 
present  time,  are  known  as  the  chief  centres  of  endemic  idiocy,  accom- 
panied by  goitre  and  physical  deformity. 

Naturally,  attempts  have  not  been  wanting  to  refer  the  origin  of  the 
disease  to  certain  definite  relations  in  the  cretin  districts.  Each  observer 
attached  most  importance  to  the  circumstances  which  seemed  most  strik- 
ing in  his  district,  and  in  this  respect  everything  wliich  could  possibly  be 
brought  forward  has  been  discussed :  sometimes  a  certain  height  above 
the  level  of  the  sea  (not  more  than  from  3-3000  feet),  deep  damp  valleys, 
stagnation  of  the  air,  frequent  inundations  with  marshiness  of  the  ground; 
sometimes  high  temperature,  great  and  sudden  changes  of  temperature; 
sometimes  deficiency  of  light  and  of  the  sun's  rays;  sometimes  the  form- 
ation of  the  soil,  in  so  far  as  the  land  has  a  certain  configuration,  or  in 
so  far  as  certain  rocks  have  a  particular  chemical  composition;  sometimes 
the  composition  of  the  water;  sometimes  want  of  iodine  in  the  water  and 
in  the  air;  sometimes  unfavorable  conditions  of  life — misery,  neglect,  dirt, 
want  of  attention  to  children,  bad  nourishment,  etc.  All  these  various  cir- 
cumstances have  been  successively  declared  to  be  the  sole,  or  at  all  events 
the  most  important,  factors  in  the  production  of  these  diseases.  But,  on 
the  other  hand,  it  is  easy  to  prove  that  goitre  and  cretinism  also  occur  in 
places  where  not  one  of  these  special  influences  (for  example,  deep  moist 
valleys,  stagnation  of  the  air,  certain  rocks,  etc. )  exist,  and  that  in  many 
places  every  one  of  these  influences  may  be  met  with,  without  either  goitre 
or  cretinism  being  prevalent. 

'  In  the  work  of  A.  Hirsch,  '  Handb.  der  histor.  geogr.  Pathologie  '  (1,  2, 
Erlangen,  1860,  p.  494),  an  excellent  epitome  of  all  that  is  as  yet  known  on  the 
subject  may  be  found. 


STATES    OF    MENTAL    WEAKNESS.  271 

We  ought  not,  however,  to  push,  this  objection  too  far.  We  can- 
not deny  tlie  certain  influence  of  marsh-miasm  on  the  production  of  in- 
termittent fever,  because  this  disease  sometimes  occurs  in  localities  where 
there  ure  no  marshes,  and  other  localities  which  are  very  marshy  are  free 
from  fever.  This  only  proves  that  the  more  immediate  and  true  causes  of 
intermittent  fever  are  generated  principally,  but  not  exclusively,  in 
marshy  localities,  and  even  in  marshy  localities  of  a  certain  nature.  In 
like  manner,  all  those  external  relations  which  have  been  enumerated  are 
tlie  more  remote  causes  of  the  production  of  definite  immediate  causes  of 
cretinism,  the  latter  are  produced  by  combinations  of  circumstances  m 
which  many  of  the  forementioned  external  conditions  may  exert  their 
influence  without  necessarily  being  always  in  like  manner  effectual. 
Certain  of  these  circumstances  also  may  manifest  themselves  more  con- 
stantly, and  therefore  lay  claim  to  greater  importance;  while  others  are 
evidently  subordinate  and  accessory.  To  the  latter,  for  example,  belong 
those  which  we  have  termed  unfavorable  social  conditions.'  Misery, 
dirt,  neglect,  mismanagement  of  children,  ignorance  and  superstition, 
may  be  found  in  their  greatest  degree  in  many  places  where  there  is  no 
trace  of  cretinism;  and  in  the  cretin  districts  the  disease  is  not  rare,  even 
in  well-to-do  and  wealthy  families.  Likewise,  there  are  a  number  of 
mountainous  districts  with  deep  valleys  where  there  is  no  trace  of  goitre 
or  cretinism,  and  cretinism  often  occurs  in  level  districts  and  in  very  open 
valleys. 

In  my  opinion,  humidity  of  the  soil  and  of  the  air,  owing  to  water 
found  underground,  inundations,  many  streams,  constant  mists,  are 
amongst  the  most  important  circumstances.  I  believe  also  (and  the 
work  of  Hirsch  points  to  the  same  conclusion)  that  the  amount  of 
magnesia  in  the  soil  (which  is  not  to  be  confounded  with  the  amount  of 
magnesia  in  the  drinking-water)  exerts  a  certain  influence.  All  the 
other  external  conditions  which  "have  been  enumerated  are  each  only  to 
be  found  in  certain  individual  cretin  districts,  and  not  in  the  majority  of 
them. 

Concerning  the  more  immediate  and  true  causes  of  cretinism,  how- 
ever, to  which  the  circumstances  wliich  have  been  mentioned  stand  only 
as  external  causes,  we  can  give  no  definite  information.  They  are  called, 
in  the  present  state  of  science,  miasm  or  morbid  poison,  and  compared  to 
the  malaria  of  intermittent  fever.  These  miasms,  which,  as  in  the  latter 
disease,  may  be  contained  in  the  air  or  in  the  drinking-water,  act  feebly 
upon  the  mass  of  the  population,  and  strongly  upon  a  few,  who  then  ex- 
perience the  full  effects  of  the  poison.  The  malady  is  now  considered  as 
an  infectious  disease,  as  it  is  a  constitutional  affection.  The  limitation  of 
goitre  and  cretinism  to  a  tract  of  country,  often  very  small,  is  favorable 
to  this  mode  of  view,  just  as  it  is  to  the  theory  of  the  production  of  inter- 
mittent fever.  Amongst  the  many  differences  which  the  latter  disease 
presents  from  cretinism,  the  fact  is  especially  prominent  that  cretinism 
once  produced  "  by  miasm"  is  decidedly  capable  of  being  transmitted  to 
the  children,  probably  of  more  than  one  generation. 

In  many  localities  where  goitre  and  cretinism  were  formerly  very  pre- 
valent, they  have  in  recent  times  much  diminished  (like  intermittent 

'In  the  work  of  Georgens  and  Deinhardt,  '  Die  Heilpadagogik,  etc.,'  Leipzig, 
1861,  p.  201,  we  find,  "  Endemic  idiocy  is  prevalent  only  in  places  which  are  be- 
hind in  civilization."  This  is  not  correct.  The  two  villages  in  the  neighborhood 
of  Tiibingen  where  cretinism  is  endemic,  are  no  more  behind  in  civilization  tlian 
100  other  villages  which  are  free  from  it. 


272  STATES    OF    MENTAL    WEAKNESS. 

fever)  under  the  influence  of  better  regulation  of  the  courses  of  rivers, 
the  draining  of  marshy  ground,  and  generally  imjjroved  hygienic  arrange- 
ments: in  many  places,  indeed,  they  have  completely  disappeared.  (Such 
diminution  has  been  remarked,  for  example,  by  Tourdes  in  the  neighbor- 
hood of  Strasburg;  and,  according  to  Zillner,  the  number  of  cretins  in 
Salzburg  has  diminished  to  about  one-fourth  between  the  year  1780  and 
the  present  time:  tlie  same  may  be  said  of  many  other  places.)'  A  pro- 
found regeneration  of  race  through  immigration  and  marriages  contracted 
with  the  strangers — above  all,  through  the  greater  commercial  activity  of 
modern  times,  perhaps  also  the  greater  awakening  of  the  intelligence  and 
activity  of  the  inhabitants  through  the  same  cause — may  likewise  tend 
to  this  result.  In  few  places  do  goitre  and  cretinism  seem  to  have  in- 
creased in  modern  times. 

According  to  the  view  here  adopted,  and  in  recent  times  pretty  generally  ac- 
cepted, endemic  goitre  and  cretinism  ai-e,  to  a  certain  extent,  specific  diseases 
generated  by  a  specific  toxic  cause  of  a  miasmatic  nature.  I  cannot  oppose  this 
view,  wliich  has  much  in  its  favor,  and  can  show  that  many  recent  attempts  to 
explain  the  production  of  these  endemic  diseases  by  amiiltitude  of  heterogeneous 
causes  have  been  unsuccessful.  Still,  we  must  not  place  too  much  confidence 
upon  this  mode  of  viewing  the  matter,  remembering  that  goitre  also  often  occurs 
sporadically;  that  the  causes  of  its  production  are  almost  unknown;  that  endemic 
goitre  presents  no  distinctive  peculiarities  from  the  sporadic  for jii:  that  conse- 
quently, therefore,  we  may  suppose  that  unknown  causes  also  operate  in  endemic 
goitre;  and  that  the  connection  between  the  development  of  goitre  and  cranial 
synostoses,  and  diseases  of  the  bones  generally,  which  perhaps  constitute  the 
chief  causes  of  cretinism,  is  altogether  obscure  and  problematical — that  it  is  even 
without  pathological  analogy  to  admit  that  closure  of  the  sutures  and  ossifications 
might  be  caused  by  miasmatic  poison. 

The  great  influence  of  humidity  in  the  causation  of  cretinism  is  demonstrated 
by  a  number  of  facts  both  genei-al  and  special,  and,  just  as  in  intermittent  fever, 
even  local  dampness,  confined  to  a  house  or  to  a  block  of  houses,  may  generate 
the  peculiar  morbid  influence.  Like  intermittent  fever,  cretinism  has  been  seen 
to  diminish  rapidly  in  consequence  of  the  better  regulation  of  the  courses  of 
rivers.  But  even  in  regard  to  these  facts,  examples  of  totally  different  experi- 
ences are  not  wanting.  There  are,  analogous  to  the  mountain  fevers,  certain  dry 
and  arid  localities  where  goitre  and  cretinism  are  endemic  (Fabre,  '  Traite,'  1.  c, 
p.  56);  and  we  have  many  examples  of  very  humid  countries  (Holland  for  exam- 
ple) where  there  is  no  endemic  disease. 

In  many  localities  intermittent  fever  is  itself  frequently  observed  side  by  side 
with  cretinism.  Analogous  causes  (paludal)  appear,  on  the  one  hand,  to  generate 
cretinism,  on  the  other,  intermittent  fever,  splenic  enlargement,  and  cachexia. 
It  is  especially  remarkable  that  in  those  places  the  thyroideal  enlargement  some- 
times occurs  acutely,  and  to  a  certain  degree  epidemically,  analogous  to  the  acute 
intermittent  processes,  as  if  a  (not  quite  identical  with  that  of  intermittent 
fever)  miasmatic  poison  occasionally  acted  rapidly  and  with  great  intensity  upon 
the  population.  Thus,  according  to  Zillner.^  there  occasionally  occur  in  Salzbm-g 
acute  enlargement  of  the  thyroid  gland,  acute  enlargement  of  the  parotids,  of 
the  spleen,  and  in  some  instances,  of  almost  the  entire  lymphatic  system,  or 
together  with  intermittent  fever,  furuncles,  glandular  suppurations,  etc. — circum- 
stances which  demonstrate  the  existence  of  an  intimate  connection  between  the 
production  of  goitre  and  the  malaria,  and  besides,  in  an  etiological  point  of  view, 
between  endemic  goitre  and  cretinism.  To  alleged  cases,  in  which,  after  dimi- 
nution of  the  goitre  in  an  idiot,  by  operation  or  by  other  treatment,  the  mental 
state  improved, **  I  can  accord  no  great  importance. 

The  very  numerous  investigations  regarding  the  geological  composition  of  the 
soil,  in  the  goitre  and  cretin  districts,  permit  us  to  assume  at  all  events  several 

•  Fodere  remarked,  moreover,  in  1793,  that  the  amount  of  goitre  and  cretinism 
had  considerably  diminished  within  a  certain  number  of  years. 

^  L.  c  ,  p.  229.  Examples  of  epidemic  goitre  may  also  be  found  in  Hirsch,  1.  c, 
p.  452. 

3  Arthaud,  '  Gazette  Med.,'  1855,  p.  428;  Fabre,  1.  c,  p.  240. 


STATES    OF    MENTAL    WEAKNESS.  273 

extremely  interesting  facts.  Both  diseases,  especially  cretinism,  occur  very 
rarely  upon  pure  limestone  (Jurassic'  limestone  also  on  chalk  formations) ;  they 
are  very  rare  also  upon  granite  and  gneiss  (in  Savoy,  in  certain  regions  of  the 
Vosges,  more  Irequently  in  the  northern  Alps  i;  they  are,  on  the  contrary,  very 
frequent  upon  dolomite,  clay  slate,  etc.,  also  (at  all  events,  in  Wiirtemberg)  upon 
yellow  sandstone.  In  this  country,  the  localities  most  infected  are  those  in  which 
the  soil  is  composed  of  freestone,  in  the  neighborhood  of  which  lie  beds  of  marl 
intersected  by  strata  of  gypsum,  from  which  the  population  obtain  their  drinking 
water.     (Sich.,  '  Wiirtemb.  Jahrbiicher,'  1855,  2.) 

The  assertion  of  Grange  (1855),  that  a  great  amount  of  magnesia  in  the  drink- 
ing water  is  the  essential  cause  of  goitre  and  cretinism,  has  been  completely  re- 
futed. Niepce  found  in  those  districts  of  France  in  which  cretinism  is  most 
endemic,  that  there  was  not  one  atom  of  magnesia  in  the  water:  in  another 
locality,  where,  according  to  Grange,  the  goitre  almost  disappeared  when  the 
patients  were  provided  with  another  kind  of  water,  Niepce  found  a  great  deal  of 
magnesia  in  this  new  water.  In  the  neighborhood  of  .Strasburg,  magnesia  was 
found  in  the  water  of  certain  districts  where  goitre  and  cretinism  are  not  more 
frequent  than  in  others  where  the  water  is  free  from  magnesia  (Tourdes).  The 
theory  which  attributes  cretinism  to  the  presence  of  calcareous  salts  in  the  water 
requires  no  further  refutation. 

Tlie  statements  of  Chatin  regarding  the  presence  of  iodine  in  the  air,  water, 
and  lood,  and  upon  the  absence  of  iodine  in  the  goitre  and  cretin  districts,  created 
a  great  sensation,  although  from  the  first  they  appeared  improbable.  They  have 
been  questioned  and  refuted  on  all  sides,  and  the  whole  affair  appears  at  best  to  be 
explicable  by  the  employment  of  impm-e  reagents.  See  Fabre,  'Traite,' p.  83; 
De  Luca,  'Comptes  rendus,'  vol.  xlix.,  p.  170;  vol.  Ivii.,  1858;  Cloez,  '  L'Institut,' 
1857,  Juin. 

§  171.  That  the  local  causes,  whatever  they  may  be,  are  alone  suffi- 
cient to  produce  fully  developed  cretinism,  is  demonstrated  by  the  fre- 
quently occurring  circumstance,  that  families  entirely  free  from  any 
special  predisposition,  that  parents  who  hitherto  had  always  healthy 
cliildren,  had  children  complete  cretins  soon  after  taking  up  their  resi- 
dence in  the  locality."  If  the  statement  of  Niepce  be  correct,'  that  the 
foundlings  of  Grenoble  and  Marseilles — districts  where  cretinism  is  un- 
known— become  goitrous  and  cretins  when  given  out  to  nurse  in  the  in- 
fected villages  of  Isere  and  Hautes-Alps,  it  would  prove  that  the  endemic 
cause  may  exercise  its  influence  for  a  certain  time  after  birth;  indeed,  a 
healthy  child  runs  the  risk  of  becoming  a  cretin  up  to  the  fourth  (Maiiei), 
and  even  to  the  seventh  year.  It  is  self-evident  that  these  local  causes 
can  only  be  rendered  harmless  by  removal  from  the  infected  locality. 

But  there  is  another  important  cause  of  cretinism;  cretinism  is  liere- 
ditary.  The  child  of  a  male  or  female  cretin,  begotten  and  reared  be- 
yond the  reach  of  the  endemic  cause,  may  be  a  cretin;  and  it  requires 
not  only  removal  from  the  infected  district,  but  also  repeated  renewal  of 
the  blood  by  marriages  into  healthy  families,  to  cause  cretinism  finally  to 
disappear  in  the  second  or  third  generation  (Billet) — and  even  then 
traces  of  it  may  still  exist.  Amongst  the  constant  population  of  these 
districts,  the  action  of  the  endemic  and  of  the  hereditary  influences  can- 
not be  individually  and  separately  distinguished:  when  a  cliild  comes  into 
the  world  a  complete  cretin,  we  do  not  know  whether  a  powerful  mias- 
matic influence  acted  upon  the  fcetus,  or  whether  it  is  to  hereditary  influ- 

'  These  facts  are  observed  in  very  different  countries.  They  are  especially 
evident  in  Wiirtemberg,  where,  otherwise,  cretinism  is  so  general:  it  is  the  same 
in  Savoy  ('  Sardinische  Commission,'  Billet,  Garbiglietti). 

'^  See  especially  the  communication  to  the  Academy  of  Sciences  January  16th, 
1854,  in  which  he  described  the  journey  during  which  he  made  those  investiga- 
tions which  enabled  him  ' '  to  draw  a  great  line  upon  the  map  of  Europe  which, 
demonstrated  the  reciprocity  of  the  dissemination  of  iodine  and  of  goitre." 

*  Niepce,  1.  c,  p.  493.     The  statement  has  been  contradicted. 

18 


274:  STATES    OF    MENTAL    WEAKNESS. 

ences  that  the  cretinism  is  due.  It  is  the  same  with  the  many  children 
in  the  cretin  districts  wlio  are  born  apparently  healthy,  but  m  from  three 
to  six  months  j^resent  evident  symptoms  of  the  affection:  we  cannot  tell 
whether  it  is  to  hereditary  influences,  or  to  the  endemic  cause  which 
now  acts  upon  them  for  the  first  time,  or  to  both  circumstances  together, 
that  this  is  due.  I  incline  to  the  opinion  of  the  Sardinian  Commission 
(loc.  cit.,  p.  194),  who  consider  hereditary  influence  to  be  the  most 
powerful  cause. 

Cretins  of  the  highest  degrees  never  have  children,  because  the  males  are 
almost  always  impotent,  and  the  women  sterile.  The  children  of  a  marriage  be- 
tween a  man  who  is  in  a  moderate  degree  a  cretin,  and  a  woman  who  is  perfectly 
healthy,  are  frequently  beautiful  and  healthy;  frequently  they  are  profound 
cretins,  semi-cretins,  epileptics,  deaf  and  dumb.  In  general,  cretinism  is  trans- 
mitted more  by  the  father  than  by  the  mother  (Guggenbiihl,  Erlenmeyer).  The 
crossing  of  races  causes  the  predisposition  to  disa^jpear  only  when  the  individuals 
are  at  the  same  time  removed  from  the  infected  district.  According  to  Billet  (1. 
c,  1855,  p.  45),  it  has  long  been  the  custom  in  several  communes  of  Maurienne 
where  cretinism  is  prevalent,  for  the  young  men  to  choose  their  wives  from 
districts  free  from  goitre  and  cretinism;  but  these  ■women  all  become  goitrous, 
they  have  often  cretin  children,  and  cretinism  is  on  the  whole  not  diniinislied 
thereby.  Here  the  favorable  influence  of  crossing  of  races  is  neutralized  by  a 
very  powerful  endemic  cause.  In  a  locality  where  the  endemic  cause  was  not  so 
sti'ong,  such  gradual  renewal  of  the  blood  would,  without  doubt,  have  been 
followed  by  favorable  results. 

It  may  be  admitted  that  the  many  injurious  influences  which,  in  localities 
where  cretinisnr  is  endemic,  result  from  mismanagement  of  children,  and  the 
w^hole  mode  of  life  of  a  profoundly  degenerate,  indolent  cretin  population,  have  a 
-very  prejudicial  effect  upon  the  young:  these  influences,  however,  have  only 
the  significance  of  accessory  causes,  which  act  only  where  the  malady  is  endemic. 
Still,  it  is  important  that  they  should  be  removed;  and  it  is  certain  that  through 
proper  nurture  and  rational  early  education  of  the  children,  the  diseases  which 
lead  to  idiocy  may,  at  all  events,  be  restrained. 

An  arrestment  of  the  disease  in  endemic  cretinism  may  sometimes  be  arrived 
at  through  change  of  locality  in  early  childhood,  and  being  placed  under  favor- 
able conditions.  From  experiments  which  have  been  made  in  the  mountains  on 
this  point,  together  with  the  opinion  that  cretinism  is  never  met  with  at  a  greater 
altitude  than  2000  feet  above  the  level  of  the  sea,  the  peculiar  idea  has  arisen  that 
cretinism  may  be  cured  upon  high  mountains;  and  the  opinion  has  even  been  ex- 
ended  to  idiocy  in  general.  In  fully  confirmed  cretinism,  change  of  locality  and 
ail  other  treatment  is  generally  ineffectual;  improvement  may  occasionally  take 
place. 

§  172.  In  the  localities  where  cretinism  is  endemic,  there  is  not,  as 
we  have  already  remarked  (p.  262),  only  one  sole  and  always  identical 
type  of  degeneration,  but  all  those  types  of  cranial  and  bodily  deformities 
are  observed,  all  those  anomalies  of  form  of  the  cranium,  especially  the 
various  synostotic  forms — synostosis  as  well  of  the  cranial  arch  as  of  the 
cranial  base,  which  we  have  already  described  (§  161).  The  most  com- 
mon deformities  are  the  examples  of  moderate  microcephalus,  especially 
the  brachycephalic  forms  in  all  their  modifications.'  It  is  likewise 
an  irrefutable  fact  that  endemic  cretinism  presents  certain  modifica- 
tions in  the  various  localities  in  which  it  occurs:  for  example,  the 
cretins  in  Salzburg  are  in  general  a  little  different  from  those  in  Switzer- 
land. The  synosto-basilar  form  which  we  have  described  (§166)  as  the 
cretin  type  in  the  strict  sense,  with  large  head,  small  unsightly  thick  body, 

'  G.  Jager  has  brought  forward  some  interesting  facts  concerning  the  occur- 
rence of  a  high  degree  of  microcephalus  (monkey-heads)  in  certain  families  in  a 
cretin  village  in  Wiirtemberg  ('  Wtirtemb.  Med.  Corresp.  Blatt,'  1839,  No.  26). 
The  Stuttgart  Cabinet  of  Natural  Histoiy  contains  a  very  interesting  cranium  of 
one  of  these  children,  described  in  the  same  journal. 


STATES    OF    MENTAL    WEAKNESS.  275 

"broad  stump  nose  with  its  root  impressed,  sad  features,  wrinkled,  partly 
hypertropliied  skin  (also  accompanied  by  the  most  extreme  dementia),  is 
nowhere  frequent  in  its  most  extreme  degrees,  as  the  extreme  examjiles 
of  all  the  forms  are  in  general  rare;  but  a  great  number  of  cases  present 
an  approximation  to  this,  and  it  is  this  whicli  gives  to  the  majority  of 
cretins  in  all  localities  where  it  is  endemic  a  common  striking  family 
likeness.  Moreover,  in  localities  where  the  endemic  influence  is  strong, 
the -whole  population  are  affected  by  it.  Besides  cretins,  half-cretins 
and  goitrous  persons,  there  are  a  number  of  weak-minded,  stunted,  ill-pro- 
portioned individuals,  many  deaf  and  dumb — many  wlio  stammer,  are 
hard  of  hearing,  squint,  etc. ;  a  general  vein  of  physical  degeneration  and 
mental  dulness  runs  through  the  whole  population;  and  even  those  Avho 
are  considered  healthy  and  clever,  are,  as  a  rule,  ugly,  stunted,  and  lazy: 
they  are  a  narrow-minded  race,  whose  want  of  intelligence  is  by  no  means 
compensated  by  largeness  of  heart. 

Cretinism  may  exist  at  birth  in  all  its  essential  characteristics,  and 
in  a  well-marked  degree;  this,  however,  occurs  very  rarely,  and,  as  a 
rule,  the  signs  in  a  newly  born  child  are  very  uncertain  or  altogether 
absent.  Many  of  these  children,  it  is  true,  come  into  the  world  with  large 
and  somewhat  irregularly  formed  heads,  wide  fontanelles,  and  abundance 
of  hair;  their  features  are  coarse,  the  neck  thick  and  short;  they  cry  very 
little,  and  sleep  almost  constantly.  But  at  about  the  third  or  fourth 
month,  sometimes  not  until  the  fifth  or  eighth  month,  the  symptoms  of 
the  malady  commence  to  show  themselves,  and  gradually  become  more 
distinct.  These  children  are  very  fat,  do  nothing  but  eat  and  sleep; 
their  mouths  are  constantly  open,  and  the  head  falls  to  one  side; 
their  countenance  is  void  of  expression;  they  seldom  weep,  and  never 
laugh:  they  manifest  no  curiosity  nor  attention.  Dentition  proceeds 
slowly;  the  teeth  soon  decay;  the  tongue  protrudes  from  the  mouth; 
the  child  understands  nothing  until  he  is  about  six  years  of  age,  and  some- 
times even  cannot  walk:  the  expression  of  mental  nullity  is  also  very 
marked;  the  morbid  process  has  run  its  course.'  Up  to  the  jaeriod  of 
puberty,  the  features  become  coarser,  more  angular,  and  older  looking; 
the  skin  is  often  dark  and  rough,  the  body  remains  small.  In  the  higher 
degrees,  mental  development  does  not  proceed  at  all,  or  merely  in  its 
simplest  form,  and  even  this  is  perverted;  the  apathetic,  gloomy  condi- 
tion of  mind  and  sentiment  preponderates:  on  the  other  hand,  in  the 
more  moderate  degrees  and  slighter  cases,  somewhat  agitated  conditions 
are  by  no  means  uncommon — these  cases  furnish  the  village  clowns. 
Puberty  is  late  in  making  its  appearance,  sometimes  not  until  the 
twentieth  year;  childhood  has  continued  till  now,  and  old  age  immedi- 
ately commences;  from  jjuberty  onwards  little  change  occurs  in  the  bodily 
or  mental  condition. 

Many  of  the  more  complete  cretins  fall  frequently,  some  of  them  daily,  into  a 
state  of  immobility,  of  half  sleep  or  suspension  of  all  the  physical  and  mental 
powers.  This  state  may  evidently  be  considered  as  analogous  to  epilepsy  or  to 
epileptic  vertigo  (there  also  occur  at  the  same  time  irregular  movements  of  the 


'  Iphofen  (ii.,  p.  216)  cites  an  example  of  a  "cretin"  who  was  healthy  and 
clever  up  to  the  age  of  five;  then  he  became  epileptic,  these  increased,  and  he 
gradually  became  "a  cretin."  Cases  of  this  kind,  even  where  the  affection  is  en- 
demic, admit  of  great  doubt  whether  they  ought  to  be  considered  as  cases  of  en- 
demic disease,  or  of  accidental  cerebral  disease,  as  in  sporadic  idiocy.  It  does  not 
necessarily  follow  that  every  case  which  occurs  in  the  infected  locality  must  be 
the  product  of  the  endemic  cause. 


276  STATES    OF    MENTAL    WEAKNESS. 

head  and  body,  rolling  of  the  eyes,  etc.).  In  regard  to  the  further  physical  and 
mental  peculiarities  of  cretins,  I  must  refer  the  reader  to  the  many  special  works 
upon  the  subject,  especially  to  the  '  Comptes  rendus'  of  the  Sardinian  Commission. 
It  does  not  lie  within  the  province  of  this  work  to  enter  into  minute  details  on 
this  subject. 


IMPORTANT    COMPLICATIONS    OF    INSANITY.  5377 


CHAPTER  lY. 
ON  SEVERAL  IMPORTANT  COMPLICATIONS   OF  INSANITY. 

§  173.  The  various  forms  of  mental  disease  which  have  been  de- 
scribed, especially  those  mentioned  in  the  second  and  third  chapters,  are 
sometimes  accompanied  by  serious  disorders,  in  particular  by  certain 
severe  affections  of  the  motory  nervous  system,  which — although  inti- 
mately and  immediately  connected  with  the  disease  of  the  brain  from 
which  the  insanity  also  results — present  such  importance,  and,  to  a  certain 
extent,  such  a  degree  of  specialty,  that  they  may  be  regarded  as  com- 
plications of  the  insanity.  By  these  complications,  therefore,  are  not  to 
be  understood  all  the  diseases  which  may  affect  the  insane;  these  are 
innumerable;  indeed,  we  scarcely  know  any  disease  which  is  not  to  be 
met  with  along  with  insanity.  The  opinion  formerly  held,  that  the 
insane  were  exempt  from  epidemic  diseases,  was  completely  refuted  in  the 
days  of  Pinel  by  the  spread  of  malignant  typhus  fever,  which  prevailed 
in  the  ordinary  wards  of  the  hospital,  to  the  division  for  the  insane;  and 
since  then,  on  more  than  one  occasion,  outbreaks  of  cholera  have  proved 
the  erroneousness  of  this  opinion.  All  the  disorders,  therefore,  which 
;are  known  to  special  pathology,  may  occur  in  the  insane.  Here,  however, 
we  have  to  do  only  with  the  study  of  those  complications  which  are 
directly  connected  with  the  insanity — those  serious  disorders  of  sensation 
and  movement  which,  themselves  symptoms  of  profound  disease  of  the 
brain,  constitute  a  part  of  the  history  of  the  insanity,  and  are  here  only 
formally  separated  from  it  in  order  that  we  may  be  enabled  to  study  them 
more  in  detail. 

It  has  been  considered  incorrect  to  consider  these  disorders  as  complications 
when  they  are  the  result  of  the  same  cerebral  disease  which  produces  the  insanity. 
How  far  this  is  correct,  is  certainly  as  well  known  to  the  author  as  to  his  critics; 
he  does  not  mean,  by  complications  of  insanity,  complications  of  cerebral  diseases 
with  other  diseases,  but  complications  of  the  ordinary  and  predominant  psychical 
symptoms  with  other  groups  of  symptoms  which  in  the  great  majority  of  mental 
diseases  are  altogether  absent. 

§  174.  Of  these  disorders,  tlie  so-called  general  {incomplete)  faraly- 
si^  or.  account  of  its  frequency,  the  peculiarity  of  its  course,  and  its 
highly  unfavorable  prognosis,  merits  the  greatest  share  of  our  attention. 
To  the  French  physicians  (Bayle,  Calmeil,  Delaye,  etc.)  belongs  the  credit 
of  having  first  minutely  observed  this  affection;  and  it  has,  to  the  present 
time,  been  a  favorite  subject  of  study  with  the  medical  psychologists  of 
this  country.  Several  German  works,  however,  have  recently  contributed 
greatly  to  advance  our  knowledge  of  this  disease. 

Of  the  abundant  literature  of  general  paralysis,  the  following  is  the  most  im- 
portant:—Bayle,  'Rech.  sur  les  Mai.  Ment.,' Paris,  1832:  further— '  Maladies  du 
Cerveau,'  1826,  and  'Annales  Med.  Psychol.,'  1855,  vii.,  p.  409;  Delaye,  'Cons,  sur 
Tine  espece  de  Paralysie,'  etc.,  Paris,  1824;  Calmeil,  'De  la  Paralysie,'  etc.,  Paris, 
1826;  Duchek,  Prager's  '  Vierteljahrsschrift,'  Bd.  xxix.,  1851,  p.  1;  Hoffmann, 
*Giinsburgs  Zeitschr.,'  Bd.  i-viii.,  1850-58;  Baillarger,  numerous  minor  papers  in 
^Ann.   Med.  Psych.,'  1853-59;  J.  Falret,  'Rech.  sur  la  Folie  paralytique,' Par., 


278  IMPORTANT    COMPLICATIOJSrS    OF    INSANITY. 

1853,  and  'Archives  Gen.,  1858,  ii.,  p.  200;  Joflfe,  'Zeitschr.  der  k.k.  Ges.  der 
Aerztezu  Wien,'  xiii.,  1857,  p.  675;  L.  Meyer, '  Annal.  des  Charite-Krankenhauses,* 
viii.,  2,  1858,  p.  44;  Erlenmeyer,  '  Die  Geliirn-Atrophie  der  Erwaclisenen,'  3d 
edition,  1857;  Austin,  '  A  Practical  Account  of  General  Paralysis,  Lond.,  1859; 
Parchappe,  '  De  la  Folie  paralytique,'  Paris,  1859. 

This  paralysis  is  never  met  with  in  individuals  who  are  mentally 
healthy;  that  is,  it  depends  upon  a  disease  of  the  brain  which  is  always 
so  severe  as  to  number  profound  insanity  amongst  its  symptoms.  The 
mental  symptoms  either  appear  simultaneously  with  the  disorder  of  move- 
ment— or  most  frequently — they  precede  for  a  certain  time  the  manifesta- 
tion of  the  motory  symptoms,  or — much  more  rarel}' — the  paralytic  ajipear- 
ances  Avere  observed  for  a  short  time  before  the  development  of  the  in- 
sanity. 

Since  the  publication  of  the  first  edition  of  this  work,  the  question  whether 
general  paralysis  might  arise  without  mental  disturbance,  in  persons  mentally 
healthy,  has  been  much  discussed;  but  the  subject  has  not  always  been  treated 
with  that  clearness  and  experience  which  is  so  desirable.  In  opposition  to  the  few 
who  answer  this  question  in  the  affirmative  (  Requin,  "Sanze,  and  to  a  certain  de- 
gree Baillarger),  it  was  not  difficult  to  show  that  the  various  states  of  progressive 
paralysis  in  the  sane  are  quite  different  from  this  special  form,  and  that  the  latter 
is  also  essentially  distinct  from  many  other  paralytic  conditions  uiith  mental  de- 
rangement (for  example,  paralysis  owing  to  apoplexy,  tumors  of  the  brain,  etc.); 
indeed,  that  by  no  means  does  every  general  and  progressive  state  of  muscular 
weakness,  in  part  proceeding  to  paralysis,  in  the  insane  or  mentally  iveak  belong 
to  this  special  form  (thus  the  muscular  weakness  which  accompanies  senile  de- 
mentia, or  chronic  alcoholismus,  or  the  progressive  spinal  paralysis  which  some- 
times accidentally  complicates  insanity).  In  this  special  form,  the  progressive 
muscular  weakness  and  the  insanity  proceed  from  the  same  cerebral  disease;  and 
the  latter  differs  in  many  points  so  distinctly  from  the  cerebral  affections  which 
lie  at  the  foundation  of  the  other  mental  disorders,  that  it  is  now  established  that 
it  ought  to  be  considered  as  a  special  form  (general  paralysis,  paralytic  dementia, 
folie  paralytique). 

The  first  symptoms  which  usher  in  this  cerebral  affection  are  very  often  psy- 
chical, or,  in  other  words,  the  motory  disturbance  occurs  in  individuals  already 
mentally  deranged.  Nevertheless,  in  these  cases  the  first  muscular  symptoms 
usually  appear  very  shortly  (within  a  few  months,  or  even  weeks)  after  the  com- 
mencement of  the  psychical  symptoms.  That  cases  also  occur  where  the  first 
appearances  of  the  paralysis  preceded  the  psychical  symptoms,  has  been  already 
asserted  in  the  first  edition  of  this  work.  Since  then,  Baillarger  has  laid  especial 
stress  upon  this  mode  of  commencement,  and  in  one  of  his  works  has  even  gone 
so  far  as  to  declare  that  the  paralysis  is  the  primary  and  leading  symptom  of  the 
disease,  and  the  insanity  more  secondary  and  accessoiy.  Hoffmann  states  the 
number  of  these  cases  at  18  per  cent  of  his  observations;  and  it  is  of  course  possi- 
ble that  the  first,  slight  muscidar  disorders  are,  in  many  cases,  for  a  time  over- 
looked by  those  who  surround  the  patient,  and  that  accordingly  the  paralysis  pre- 
ceded, or  perhaps  occun-ed  simultaneously  with  the  mental  disease,  in  a  greater 
number  of  cases  than  was  formerly  supposed.  Still,  in  the  present  state  of  science 
we  must  assume  that  in  the  great  majority  of  cases  the  psychical  derangement 
precedes  the  paralysis. 

§  175.  The  tongue  is  always  the  organ  whose  movements  first  present 
irregularity.  The  patient  commences  to  speak  with  difficulty,  to  articu- 
late somewhat  indistinctly,  and  to  stammer.  In  this  the  tongue,  when 
protruded,  does  not  incline  to  one  side,  but  tremulous  and  occasionally 
convulsive  movements  of  it  are  observed.  This  early  symptom,  dimin- 
ished facility  of  speech,  which  soon  advances  to  stammering,  is  of  very 
great  importance;  whenever  this  is  remarked  in  an  insane  person,  he  may 
with  almost  absolute  certainty  be  considered  as  lost.  Then,  although 
these  patients  have  all  the  appearance  of  robust  health,  and  cannot  suf- 
ficiently extol  their  own  feeling  of  well-being,  there  gradually  becomes 
developed  a  series  of  the  most  various  symptoms.    At  the  same  time  that 


IMPORTANT    COMPLICATIONS    OF    INSANITY.  279 

the  speech  becomes  difficult,  more  frequently  noc  until  some  time  after,' 
a  change  in  the  gait  of  tlie  j^atient  is  observed;  he  does  not  lift  his  legs 
properly,  walks  stiffly,  involuntarily  deviates  to  one  side  when  attempting 
to  walk  straight  forward,  and  easily  stumbles  if  the  floor  he  at  all  uneven, 
— for  example,  when  going  over  a  step.  Still,  they  take  pleasure  in 
walking  about  a  great  deal;  some  of  them  even  experience  a  constant  de 
sire  for  restless  change  of  scene:  they  take  long  walks,  and,  to  the  inex- 
perienced eye,  nothing  striking  is  presented  so  long  as  they  keep  upon 
level  ground.  The  arms  remain  for  a  long  time  unimpaired.  Gradually, 
however,  while  the  pronunication  of  words  becomes  constantly  niore  in- 
distinct, so  that  Ave  occasionally  have  to  guess  what  the  patient  intends 
to  say;  the  gait  becomes  unsteady,  like  that  of  a  drunken  man;  the  feet 
are  dragged  after  him;  the  knees  appear  as  if  they  would  collapse;  he 
must  support  liimself  by  the  wall,  stumbles  every  moment,  and  frequently 
falls.  The  arms  and  hands  now  become  somewhat  stiff;  objects  are 
grasped,  as  if  convulsively,  and  occasionally  suddenly  let  fall;  all  the 
more  delicate  movements,*  such  as  writing,  sewing,  playing  the  piano, 
etc.,  gradually  become  impossible.  When  reclining,  the  patient  can 
freely  move  his  legs  and  arms;  but  these  movements  are  more  slowly  and 
stiffly  performed  than  usual.  As  the  disease  progresses,  he  can  no  longer 
maintain  himself  erect,  language  is  replaced  by  confused  and  indefinite 
sounds,  which  run  into  each  other;  even  while  sitting  or  lying  he  can 
scarcely  move  or  stretch  his  legs,  but  the  arms  and  hands  still  enjoy  com- 
parative freedom  of  movement. 

The  muscular  affection  appears  to  be  even  at  the  commencement  very  extended, 
indeed  almost  general,  although  at  the  same  time  very  feeble:  it  is  manifested 
first  of  all  in  those  organs  whose  movements  required  to  be  most  delicate  and 
precise:  the  principal  of  these  is  the  tongue,  and  difficulty  in  the  pronunciation 
of  words  is  therefore  always  a  leading  feature  in  the  picture  of  this  paralysis. 
Ordinarily,  the  movements  of  the  lips  are  also  rendered  more  difficult,  particu- 
larly in  the  formation  of  labial  sounds  (Duchek);  and  also,  apart  from  speech,  we 
frequently  remark  slight  convulsive  movements  in  the  muscles  about  the  mouth. 
In  the  upper  extremities  we  remark  at  the  commencement,  yet  without  any  act- 
ual weakness,  a  shght  tremor,  which  renders  the  movements  irregular,  awkward, 
and  constrained.  In  the  lower  extremities  it  is  at  first  lesstremulousness  than  an 
involuntary  restlessness,  a  jerking  irregular  movement  of  the  legs  in  walking. 
At  this  period  the  gait  is  rapid;  but  later,  when  the  patient  can  no  longer  walk 
owing  to  actual  weakness,  we  may  often  perceive  transient  or  more  persistent 
stiffness  in  certain  of  the  muscles  of  the  leg. 

I  believe  that  I  was  the  first  to  call  attention  to  the  fact  that  this  motory 
disorder  is  at  the  commencement  not  so  much  paralytic  as  convulsive  in  its  nature 
(1st  edition,  p.  286).  Since  then  this  point  has  been  many  times  confirmed:  see 
especially  J.  Falret,  '  Archiv,'  1.  c,  p.  202;  Duchenne,  "  De  TAtaxie  locomotrice, 
'  Archives,'  1859,  p.  62.  A  great  impairment  of  the  muscular  sensation,  which, 
for  example,  enables  the  healthy  person  to  estimate  the  degree  of  resistance  and 
the  amount  of  muscular  power  expended  in  the  performance  of  a  certain 
action,  appears  to  play  an  important  part  in  producing  the  disorder,  and  want  of 
co-ordination  and  precision  of  the  movements  (Neumann):  still  this  does  not  suf- 
fice to  explain  all  the  phenomena— for  example,  the  trembling  of  the  muscles  of 

Afterwards  an  actual  state  of  weakness  of  the  muscles  sets  in,  and  this  is  very 
general;  the  body  becomes  completely  bowed  down,  the  arms  hang  loosely  by  the 
side,  the  head  hangs  back,  the  sphincters  or  detrusory  muscles  of  the  urine  and 
intestinal  contents  become  feeble,  and,  finally,  even  the  respiratory  muscles  be- 
come paralyzed.  It  is  only  in  exceptional  cases  that  we  observe  greater  weakness 
in  one  half  of  the  body,  an  inclination  of  the  tongue  to  one  side,  obhquity  ot 
countenance;  these  exceptional  cases  appear  to  depend  upon  considerable  atrophy 
of  one-half  of  the  brain,  or  upon  unilateral  hsematomata  in  the  dura  mater. 

The  contractility  of  the  muscles  under  the  influence  of  electricity  is,  as  in  other 
forms  of  cerebral  paralysis,  always  normal  (in  contradistinction  to  peripheral  and 


280  IMPORTANT    COMPLICATIONS    OF    INSANITY. 

many  spinal  paralyses).  This,  however,  is  of  very  little  diagnostic  value,  as  it 
is  also  observed  in  a  number  of  other  paralyses  (hysterical  jjaralysis,  paralysis  I'e- 
sulting  from  a  tumor  of  the  brain,  etc.).  Duchenne,  who  established  this  fact 
in  1850,  has  published  the  further  results  of  his  eKperiments  in  '  Traite  de  I'Elec- 
tris.  loc,"  Par.,  1855,  and  especially  in  his  " Memoire  sur  I'Ataxie  locomotrice" 
('Arch,  de  Med.,'  1859,  p.  68). 

At  the  commencement  the  pupils  are  often  regularly  contracted;  afterwards 
they  again  enlarge,  but  often  unequally.  Seifert  ('  Zeitschr.  f.  Psych.,'  x.,  p.  561) 
observed,  in  twenty-five  paralytics,  seventeen  cases  of  anomaly  in  the  mobiUty  of 
the  iris.  This  irregularity  of  the  pupils,  which  sometimes  exists  for  years  before 
the  outbreak  of  the  malady,  is  not  to  be  considered  as  its  first  commencement; 
this  occurs  quite  as  frequently  in  individuals  who  afterwards  become  attacked 
with  other  forms  of  mental  disease.  Strabismus,  and  disorders  of  movement  of 
the  eye  generally,  scarcely  ever  occur;  sometimes,  but  in  a  later  stage  of  the 
disease,  a  convulsive  rolling  of  the  eyeballs  may  be  observed. 

As  to  sensibility,  the  special  senses  generally  remain  till  the  last  with- 
out any  striking  impairment;  when  the  affection  has  lasted  for  a  long 
time,  the  senses  of  taste  and  of  smell  become  less  acute,  so  that  the  pa- 
tient, for  example,  cannot  distinguish  wine  from  water.  Pain  does 
not  exist,  but  at  the  commencement  the  patient  sometimes  complains 
of  headache,  with  a  sensation  of  weight  and  confusion  in  the  head,  and  a 
slight  degree  of  yertigo.  The  cutaneous  sensibility  occasionally  presents  a 
remarkable  peculiarity.  While  it  in  all  cases  appears  at  the  commence- 
ment to  become  blunted,  and  afterwards  in  certain  cases  almost  abolished 
(so  that  the  patients  can  endure  severe  pinching  without  experiencing 
pain),  there  occasionally  occur  transitory  states  of  extreme  hypergesthesia 
of  the  cutaneous  surface,  in  which  the  slightest  touch  excites  the  most  ex- 
tended reflex  movements,  convulsions  of  all  voluntary  muscles — condi- 
tions which  present  the  greatest  similarity  to  the  symptoms  produced  in 
animals  by  a  poisonous  dose  of  strychnine.  In  a  well-marked  case  of  this 
kind  we  were  able  minutely  to  observe  this  cutaneous  hyperaesthesia 
during  the  hours  immediately  succeeding  an  attack  of  convulsion. 

Not  unfrequently,  we  observe  in  these  patients,  under  the  symptoms 
of  violent  cerebral  congestion,  sudden  attacks  of  loss  of  consciousness, 
often  accompanied  by  convulsive  attacks  resembling  those  of  epilepsy. 
These,  when  they  have  once  appeared,  are  generally  repeated  at  intervals;* 
the  patient  may  die  in  them,  but  generally  he  soon  recovers.  After  each 
attack  there  is  usually  observed  an  increase  of  the  paralysis  and  of  the 
mental  dulness;  more  rarely,  contractions  of  certain  ligaments  of  the 
forearm,  finger,  or  leg,  remain  after  an  attack. 

We  must  distinguish  between  the  slight  attacks  of  vertigo  obsei-ved  at  the 
commencement,  the  congestive  attacks  which  occur  in  the  course  of  the  disease, 
and  are  more  or  less  apoplectiform  and  combined  with  loss  of  consciousness,  and 
the  epileptiform  attacks.  In  certain  rare  cases  the  congestive  attacks  occur  at 
the  very  commencement,  so  that  the  disease  appears  to  begin  with  one  of  them: 
in  cases  of  this  sort,  however,  slight  symptoms  have  always  previously  existed. 
In  the  latter  stages  of  the  disease  they  are  seldom  altogether  absent ;  in  the  end 
they  occur  more  frequently,  and  are  of  longer  duration,  sometimes  lasting  for 
several  days.  The  epileptiform  attacks  never  make  their  appearance  until  the 
disease  is  far  advanced. 

§  176.  At  the  commencement  of  the  disease  the  i^sycliical  disorders 
do  not  always  present  the  same  character.  It  is  rarely  that  a  melancholic 
stage  does  not  exist.  This  is  sometimes  simply  depressive,  sometimes 
strongly  hypochondriacal  in  its  character.  The  first  disorders  of  move- 
ment are  very  rarely  manifested  in  the  melancholic  stage;  nevertheless, 
eases  do  occur,  as  Calmeil  (1.  c,  p.  328)  has  observed,  and  in  such  cases 
the  patients  may  retain  for  a  long  time  the  melancholic  nature  of  the 


IMPORTANT    COMPLICATIONS    OF    INSANITY.  281 

delirium,  so  that  the  depression  passes  almost  immediately  into  dementia. 
The  change  in  the  character  and  entire  nature  of  the  jjatient  is  very 
variously  exhibited  at  tlie  commencement  of  the  disease.  A  want  of 
the  former>  mental  activity  and  energy,  a  painful  anxiety  regarding 
the  most  trifling  circumstances,  are  frequently  the  first  symptoms 
observed;  amongst  the  prodromal  symptoms  we  occasionally  observe,  also, 
certain  perversions  of  the  character  and  affective  sentiments,  which  are 
often  extremely  startling,  occurring  in  patients  who  still  move  freely  in 
society,  pursue  their  avocations,  etc. :  these  may  give  rise  to  medico-legal 
questions  which  are  often  very  difficult  to  settle — especially  violations  of 
property  (sometimes  proceeding  from  the  idea  that  the  objects  in  ques- 
tion really  belong  to  them;  frequently,  also,  from  a  momentary  irresis- 
tible impulse  to  gratify  a  desire);  rude,  immodest  acts,  and  the  like. 

Whatever  the  commencement  may  be,  in  ordinary  cases  there  always 
arrives  a  period  characterized  by  a  state  of  general  psychical  excitement. 
The  first  evident  symptoms  of  the  motory  disorder  generally  correspond 
with  this — that  is,  with  the  vague  delirium  of  mania,  or  accompanied  by 
those  fixed  ideas  which  we  have  described  when  speaking  of  monomania; 
namely,,  such  as  relate  to  exaltation  of  the  person,  to  grandeur,  which, 
on  account  of  their  frequent  connection  with  general  paralysis,  are 
correctly  considered  of  great  prognostic  value  {monomanie  des grandeurs). 
These  patients  are  active,  busy,  speak  a  great  deal,  are  constantly  in 
movement,  buy  and  sell,  plan  great  schemes;  their  manner  is,  indeed, 
odd,  peculiar,  and  extravagant,  but  they  are  only  recognized  as  mentally 
diseased  by  the  initiated.  Soon  they  allow  themselves  greater  freedom, 
become  more  and  more  restless;  manifest  in  everything  their  satisfied,  ex- 
alted frame  of  mind;  spend  lavishly  and  make  magnificent  presents; 
recount  imaginary  histories,  in  which  they  frequently  contradict  them- 
selves; now  and  then  they  give  offence  by  their  habits  of  drunkenness 
and  gross  indecencies:  in  short,  they  make  themselves — to  use  Neumann's 
appropriate  expression — unbearable.  Should  the  patients  be  admitted 
at  this  period  into  an  asylum,  they  generally,  under  isolation  and  appro- 
priate diet,  rapidly  become  somewhat  more  calm;  but  usually  this  is  of 
only  short  duration,  and  in  the  great  majority  of  cases  there  are  now  de- 
veloped the  specially  characteristic  ideas  of  greatness,  in  which  all  that 
relates  to  the  person  of  the  patient  assumes  in  his  eyes  colossal  dimen- 
sions, and  is  expressed  by  him  in  the  most  superlative  language  and 
liighest  numbers.  At  the  same  time,  however,  the  intellect,  character, 
and  emotions,  all  assume  the  character  of  weakness.  In  their  delirious 
ideas  they  often  contradict  themselves;  they  do  not  persist  in  them,  but 
soon  forget  and  pass  on  to  others:  the  circle  of  the  ideas  is,  in  spite  of 
their  apparently  active  production,  very  limited;  incoherence  soon  be- 
comes (particularly  in  writing)  marked;  and  it  is  in  the  highest  degree 
remarkable  how  all  things,  even  the  most  absurd,  are  at  once  accepted  as 
realities  without  the  least  internal  opposition:  the  ego  becomes  quite  in- 
capable of  resistance,  and  is  entirely  taken  possession  of  and  subdued  by 
them.  Their  will  is  weak;  they  appear  violent,  but  are  pliable  as  children, 
easily  subdued,  and  they  are  also  somewhat  mobile  and  lachrymose  in 
their  nature. 

The  weakness  of  the  mental  faculties  becomes  more  and  more  pro- 
found in  j)roportion  as  the  paralytic  appearances  become  more  marked; 
the  patient  loses  his  memory,  the  capability  of  mental  association,  all 
sense  of  duty;  he  becomes  completely  indifferent,  dirty  in  his  habits,  etc. 
Prom  this  time  the  dementia  progresses  step  by  step  with  the  paralysis: 


282  IMPORTANT    COMPLICATIONg"  OF    INSANITY. 

still,  iu  certain  patients  the  course  of  the  disease  is  varied,  sometimes  hy 
increased  restlessness — sometimes  even  by  attacks  of  mania,  vociferation, 
and  desire  to  destroy.  Certain  patients  continue  for  a  long  time  to  mani- 
fest, but  without  any  actual  sense  of  what  they  say,  those  extravagant 
ideas  of  possession  of  provinces,  riches,  worlds,  millions,  etc.,  variously 
modified  according  to  the  degree  of  education.  The  one'  possesses  mil- 
lions of  billions — all  the  world  belongs  to  him,  all  things  were  made  by 
him,  etc.  Another  has  built  the  most  splendid  castle,  bought  all  Italy, 
plundered  Asia,  destroyed  the  bridge  from  the  earth  to  the  moon,  trans- 
ferred the  Chinese  to  Paris,  is  himself  800  feet  high,  etc.  Others  walk 
100  leagues  in  a  day,  write  100  tragedies  and  1000  poems  in  the  same 
space  of  time — have  heads  made  of  diamonds  set  in  gold,  horses  and 
palaces  made  of  gold,  etc. 

Moreover,  the  ideas  of  greatness  are  not  always  so  completely  developed  as 
might  be  supposed  from  the  descriptions  given  of  individual  cases.  Exclusive  of 
those  rare  cases  in  which  the  entire  mental  disorder  had  for  a  long  time  the 
character  of  depression,  and  no  special  stage  of  mania  ever  existed,  conditions  are 
also  frequently  observed  where  the  excited  and  elevated  disposition  was  mani- 
fested rather  as  a  general  lively,  happy,  self-contented  manner,  than  iu  many 
exalted  ideas,  or  where  the  latter  are  at  least  comparatively  unassuming  in  their 
character;  for  example,  in  women,  simply  the  conviction  that  they  have  a  great 
many  fine  dresses  at  home,  etc.  Sometimes  the  dementia  forms  the  base  and  the 
background  of  all  the  psychical  phenoinena,  and  also  soon  manifests  itself  in  the 
expressionless  countenance  and  contented  residence  in  the  asylum.  The  gigantic 
ideas  are  now  expressed,  as  it  were,  mechanically,  as  a  remnant  of  the  former 
activity  of  the  mental  processes. 

In  the  latter  periods  of  this  affection  these  ideas  completely  disappear  : 
the  patient  is  in  the  extreme  stage  of  mental  decay;  he  is  as  little  capable 
of  having  a  complete  idea  as  he  is  of  pronouncing  a  proper  word;  he  is  void 
of  any  conception  of  his  whereabouts:  even  the  primary  instincts,  as  the 
desire  for  food,  disappear,  and  tbe  patient  requires  not  only  to  be  fed, 
but  the  food  must  often  be  pushed  backwards  in  the  mouth. 

The  appetite,  the  digestion,  and  nutrition  are,  at  the  commencement, 
and  during  a  considerable  period  of  the  course  of  the  disease,  well  main- 
tained: the  patients  then  eat  well,  and  even  greedily;  their  appearance  is 
often  good,  and  they  fvequently  have  a  tendency  to  become  fat:  a  remark- 
able dryness  of  the  skin,  with  considerable  separation  of  the  epidermis, 
were  the  only  circumstances  which  struck  us  in  certain  cases  where  the 
cutaneous  sensibility  was  diminished.  It  is  not  generally  until  the  ad- 
vanced period  that  the  patients  become  emaciated;  gangrenous  spots  ap- 
pear in  various  parts  of  the  skin,  especiallly  of  the  back;  large  abscesses 
form;  extensive  suppurations  and  infiltrations  of  the  extremities  occur, 
and  the  patients  sink  under  hectic  fever,  which  in  many  cases  is  connected 
with  pyemia — in  others  with  acute  or  chronic  intestinal  catarrh,  accom- 
panied by  profuse  diarrhoea  and  ulceration  of  the  intestines;  at  other 
times  it  is  connected  with  general  tuberculosis.  Some  also  die  of  pneu- 
monia, particularly  of  lobular  pneumonia,  consecutive  to  chronic  bronchial 
catarrh;  others  from  accident,  etc. 

The  work  of  L.  Meyer  (1.  c.)  renders  it  very  probable  that  the  morbid  process 
in  the  cranium  which  lies  at  the  foundation  of  the  paralytic  mental  derangement, 
at  least  in  many  cases,  is  itself  accompanied  by  a  febrile  increase  of  temperature, 
and  that  the  maniacal  stages  are  in  particular  intimately  connected  with  this 
febrile  increase  of  temperature.  This  is,  moreover,  sometimes  very  inconsiderable 
(Meyer's  17th  observ^ation,  p.  167),  and  it  seems  to  me  still  problematical  whether 

'  See  Bayle,  '  Maladies  du  Cerveau,'  Paris,  1826,  pages  71,  210,  503. 


IMPORTANT    COMPLICATIONS    OF    INSANITY.  283 

a  distinction  between  these  forms  and  the  other  states  of  psychical  exaltation  can 
be  founded  upon  the  state  of  the  bodily  temperature.  Sander  (Virchow's  '  Archiv, ' 
XV.,  p.  160)  found  the  secretion  of  urea  comparatively  small,  even  in  patients  who 
took  their  food  well  and  became  emaciated;  he  accounts  for  this  by  diminished 
assimilation  of  the  nutritive  elements. 

§  177.  General  paralysis  of  the  insane  occurs,  according  to  all  known 
experience,  much  more  frequently  in  men  than  in  women.  According  to 
Calmeil,  there  is  one  general  ])aralytic  in  every  15  insane  in  men,  and  in 
women  1  in  50;'  according  to  Bayle,  in  Charenton  general  paralysis  was 
eight  times  more  frequent  amongst  the  males  than  amongst  the  females;^ 
Foville  calculates  31  general  paralytics  to  334  insane,  of  whom  22  are 
males  and  9  females;'  Hoffmann  found  18  paralytic  women  to  138  men; 
in  Leubus  there  were,  in  about  2700  cases,  1.376  per  cent  males,  and 
only  3.16  per  cent  females;  in  Prague,  to  03  men  there  were  G  women; 
in  Stephansfeld,  from  1835  to  1852,  ith  of  the  males  and  only  -gJ^th  of 
the  females  suffered  from  general  paralysis;  Bazire",  in  Bordeaux,  had  62 
general  paralytics  amongst  996  females,  etc.  The  causes  of  this  difference 
between  the  sexes  are  obscure:  it  may,  with  some  show  of  reason,  be  as- 
sumed that  the  more  frequent  excesses  in  spirituous  liquors  and  in  venery 
amongst  men  predispose  the  brain  to  such  affections;  perhaps  strong 
cigars  and  strong  coffee  have  a  share  in  this:  nevertheless,  cases  occur  in 
which  the  disease  sets  in  after  the  most  regular  life,  wliere  none  of  these 
causes  have  been  at  work,  and  in  particular  where  no  traces  of  former 
syphilitic  disease — a  cause  which  has  recently  been  assigned  an  important 
place  in  the  etiology  of  this  affection  (W.  Jessen) — existed. 

This  disease  almost  never  occurs  before  the  age  of  twenty,  it  is  most 
frequent  about  the  age  of  forty.  It  is  most  frequent  amongst  the  edu- 
cated classes^ — amongst  military  officers,  merchants,  government  officials, 
and  the  like;  it  is  also  very  frequent  in.  mentally  excitable  persons — in 
poets,  musicians,  learned  men,  especially  if  of  the  sanguine  temperament. 
Excessive  mental  excitement,  and,  in  a  still  greater  degree,  emotional  agita- 
tions, appear  to  be  important  factors  in  its  production.  Climate,  too, 
appears  to  exert  some  influence  upon  the  frequency  of  general  paralysis; 
it  is  not  so  common  in  many  southern  countries  (for  example,  in  the 
South  of  France)  as  in  the  north. 

General  paralysis  is  nowhere  more  common  than  in  France,  or,  at  least,  in 
the  asylums  of  Paris.  According  to  Bayle  (1855),  the  proportion  of  paralytics  is 
1  in  4."  (Baillarger,  on  the  other  hand,  gives  for  Bicetre  and  Salpetriere  together 
the  proportion  of  1  to  16.)  In  Vienna  the  disease  is  common  (in  1855  and  1856 
about  12  per  cent  of  the  admissions,  to  which  afterwards  a  considerable  number 
would  of  course  be  added);  in  the  Tyrol  Asylum  (Stoltz,  1851)  more  frequent  than 
in  Prague  (Duchek).  The  very  large  proportion  which  Bini  gives  for  the  asylum 
at  Florence  is  remarkable  (about  18  per  cent  of  the  admissions);  it  is  also  worthy 
of  note  that  Guislain,  in  the  few  years  previous  to  1850,  remarked,  in  his  sphere 
of  observation  in  Ghent,  a  considerable  diminution  in  the  number  of  paralytics 
('Leg.  or.,' ii.,  p.  104),  while  elsewhere  it  was  universally  found  to  be  on  the 
increase.  It  would  be  interesting  to  compare  all  the  existing  statistics  of  general 
paralysis;  many  errors  might  thus  be  corrected,  and  greater  light  thrown  upon 
its  true  causes,  which  are  as  yet  buried  in  obscurity. 

§  178.  The  duration  of  general  paralysis  varies  from  several  months 


'L.  c.,p.  371. 
'L.  c,  p.  403. 

3 '  Diet,  de  Med.  et  de  Chir.  Prat.,'  art.  "  Alienation,"  p.  505. 
^ '  Ann.  Med.  Psychol.,'  vi.,  1854,  p.  658. 

^  In  Leubus,  there  were  of  all  the  male  patients  13.76  affected,  but  of  those  in 
the  higher  ranks  of  life  25.00. 


284  IMPORTANT    COMPLICATIONS    OF    INSANITY. 

to  about  three  years:  exceptional  cases,  indeed,  occur,  in  which  the  uiS- 
ease  hasts  for  a  longer  period,  even  for  ten  years  (Brierre,  Trelat);  still, 
not  without  long  periods  of  intermission.  When  nursed  in  their  fami- 
lies, these  patients  live  longer  than  in  asylums,  as  their  care  in  the  higher 
degrees  demands  the  same  trouble  and  attention  as  that  of  a  young  child. 
The  course  of  the  disease  is  not  only  interrupted  unfavorably  to  the  patient, 
or  accelerated  by  the  congestive  attacks  of  which  we  have  spoken;  fre- 
quently also  we  see  the  patient  become  daily  worse  without  any  appreci- 
able cause. 

Several  examples  of  recovery,  or  at  least  of  long-continued  consider- 
able improvement — never  without  urgent  danger  of  relaj)se — have  been 
published.  Calmeil  has  observed  two  and  Bayle  six  cases  of  this  kind: 
Flemmiug,  Snell,  Ferrus,  Baillarger,  have  also  communicated  several 
cases  of  recovery.  The  immense  majority  of  the  patients,  however,  die 
within  the  given  time.  On  the  hand,  it  is  less  rare  to  observe  transitory 
improvements,  and  sometimes  even  complete  intermissions;  but  unfortu- 
nately, these  are  only  of  short  duration. 

On  the  whole,  this  affection  is  essentially  progressive  in  its  character;  but,  in 
general,  this  progression  is  rather  irregular  than  constant,  and  sometimes  even 
jerking  in  its  character.  Remissions  of  all  the  symptoms,  psycliical  as  well  as 
motory,  are  not  unfi-equent;  they  may  even  proceed  to  a  condition  in  which  the 
patient  no  longer  manifests  any  trace  of  delirium,  i-eturns  to  his  employment, 
and  only  a  slight  hesitation  in  speech  and  a  certain  degree  of  mental  and  emo- 
tional weakness  is  perceptible  to  the  initiated.  These  marked  remissions  may 
last  for  several  weeks,  and  even  for  a  year  or  a  year  and  a  half;  even  such  slight 
signs  of  intellectual  weakness  do  not  in  the  least  warrant  us  to  consider  the 
individuals  as  of  sound  mind — a  fact  which  in  a  medico-legal  point  of  view  may 
be  very  important:  as  a  rule,  the  ordinarily  recognized  signs  of  insanity  are  alto- 
gether absent  in  these  cases.  Frequently,  these  marked  intermissions  are 
suddenly  cut  short  by  a  congestive  attack,  with  which  the  patient  is  again 
plunged  into  his  former  state,  and  usually  the  disease  then  runs  rapidly  towards 
its  fatal  end. 

From  the  many  careful  and  interesting  investigations  concerning  the 
condition  of  the  brain  in  general  paralysis  (see  the  chapter  on  Pathologi- 
cal Anatomy),  we  discover  that  the  alterations  which  lie  at  the  founda- 
tion of  this  disease  are  not  exactly  similar  in  every  case.  Here  also,  as 
in  the  other  diseases  of  the  nervous  system,  different  anatomical  changes 
may  give  rise  to  the  same  groups  of  symptoms.  Ordinary  apoplexy — irri- 
tation of  the  brain,  owing  to  extravasation  of  blood — never  gives  rise 
to  this  form  of  paralysis;  on  the  contrary,  during  the  attacks  of  cere- 
bral congestion  and  loss  of  consciousness,  more  or  less  considerable  effu- 
sion of  blood  appears  to  take  place  into  the  sac  of  the  arachnoid,  which 
afterwards  either  becomes  encysted  or,  where  the  quantity  has  been  small, 
transformed  into  a  thin,  incompact  pseudo-membrane,  resembling  vege- 
tations upon  the  internal  aspect  of  the  dura  mater,  covering  the  convex 
portion  of  the  hemispheres. 

It  is  not  to  be  supposed  that  the  congestive  apoplectiform  attacks  always 
depend  upon  extravasation  of  blood  into  the  cavity  of  the  arachnoid  (haemato- 
mata);  there  are  cases  with  frequently  repeated  and  strong  attacks,  and  no 
extravasation.  Ordinary  extravasation  of  blood  into  the  brain  occurs  in  certain 
rare  cases  as  a  complication ;  it  never  lies  at  the  foundation  of  general  paralysis. 

The  diagnosis  of  paralytic  mental  disorder  is,  in  the  great  majority  of 
cases,  no  difficult  task.  It  is  based  upon  the  existence  of  the  symptoms 
we  have  been  describing;  upon  the  general  but  incomplete  character  of 
the  paralysis — its  progressive  nature;  upon  the  convulsive  character  of 
the  early  symptoms  of  the  disease — its  commencement  with  trembling  of 


IMPORTANT    COMPLICATIONS    OF    INSANITY.  285 

the  tongiie  and  of  the  lips;  upon  the  special  character  of  the  mental  de- 
rangement, particularly  the  ideas  of  greatness  and  the  rapidly  ensuing 
mental  weakness;  upon  the  irregular  course.  It  is  by  regarding  these  symp- 
toms that  we  in  general  soon  succeed  in  distinguishing  this  affection 
from  paralysis  due  to  cerebral  haemorrhage,  embolism,  encephalitis,  tu- 
mors of  the  brain;  from  hysterical  and  toxic  paralyses;  from  progressive 
spinal  paralysis,  the  tremor  of  old  age,  progressive  muscular  atrophy. 

The  great  analogy  which  exists  between  this  paralysis  and  the  insanity  con- 
nected with  it  and  di-unkenness,  mentioned  bj^  me  in  the  first  edition  of  this 
work  (p.  246),  has  since  then  been  more  minutely  described  by  Lasegue  ('  Arch. 
Gen.,'  1853,  1.,  p.  49)  and  by  Bayle  ('Ann.  Med.  Psych.,'  1855,  vii.,  p.  423).  The 
former  calls  attention  to  the  fact  that  there  are  cases  in  which  the  diagnosis  be- 
tween this  paralysis  and  alcoholismus  is  not  very  easy:  the  course  of  the  disease^ 
however,  will  always  in  these  cases  soon  lead  to  a  correct  conclusion. 

§  179.  As  the  second  important  complication  of  insanity  may  be  men- 
tioned epilepsy.  The  numerous  jjoints  of  contact  and  transition  of  the 
motory  convulsive  forms  comjjrehended  under  this  name,  to  the  more 
profound  derangements  of  the  psychical  functions,  are  manifested  partly 
in  the  symptoms  which  precede,  accompany,  and  follow  the  attack — 
partly  in  the  whole  course  of  the  disease. 

Striking  psychical  disturbances  sometimes  occur  hefore  the  attack. 
Sometimes  a  confusion  and  obscuring  of  the  consciousness  resembling 
drunkenness;  sometimes  profound  sadness — an  extremely  painful,  angry 
disposition;  sometimes  violent  hallucinations  of  all  the  senses — immedi- 
ately precede  the  attack. 

During  the  attack,  in  fully  developed  cases,  the  psychical  faculties 
are  completely  suspended;  at  least,  the  patient  cannot  remember  any 
psychical  act  that  happened  during  this  time,  although  the  expression 
of  fixed  terrified  astonishment  which  he  so  frequently  manifests  might 
awaken  the  idea  that  he  is  suffering  extreme  mental  j^ain.  There  are, 
however,  many  epileptic  conditions  in  which  we  may  recognize,  during 
the  attack,  the  existence  of  a  psychical  disorder.  Thus  we  may  frequent- 
ly observe  attacks  sometimes  preceding  and  sometimes  alternating  with 
intermittent  convulsions,  which  consist  principally  in  a  psychical  anom- 
aly, either  entirely  without,  or  with  very  limited,  disorder  of  movement 
(for  example,  contractions  of  certain  muscles  of  the  face,  movements  of 
deglutition,  relaxation  of  the  brachial  muscles),  of  which  occasionally  the 
patient  has  some  degree  of  recollection.  In  many  of  these  patients  there 
is  a  sudden  obscuring  or  suspension  of  consciousness  as  to  external  objects: 
the  eyes  become  fixed;  the  patient,  if  he  had  been  speaking,  sometimes  re- 
peatedly murmurs  the  word  last  spoken;  when  he  recovers,  he  perceives  his 
mental  absence,  and  sometimes  attempts  to  conceal  it,  or  continues  his  con- 
versation, commencing  at  the  word  at  which  he  stopped.  Such  patients 
have  subsequently  described  their  state  as  one  of  profound  mental  pain, 
with  great  incoherence  and  depression,  as  though  they  were  in  a  painful 
dream;  they  had  a  sensation  of  anxiety,  or  as  of  some  terrible  misfortune, 
without  knowing  any  reason  for  it.  Others,  after  partial  or  complete 
loss  of  consciousness,  execute  combined  movements — series  of  actions 
which  correspond  to  a  state  of  dreaming,  of  varied,  but,  in  general,  of  a 
painful  and  depressive  character.  Most  frequently  the  patients  have  no 
recollection  of  these.* 


'  'Cyclopsedia  of  Pract.  Med.,'  vol.  ii.,  art.  •'  Epilepsy,"  by  Cheyne.     See  also 
the  case  where  phantasies  were  remembered  after  the  epileptic  attack,  in  Nasse. 


286  IMPORTANT    COMPLICATIONS    OF    INSANITY. 

Immediately  after  the  attack,  the  psychical  functions  are  often  yery 
seriously  disturbed.  Sometimes  the  patient  speaks  incoherently  for  a 
long  time,  as  if  he  were  in  dementia,  and  the  intellect  does  not  recover 
its  former  state  for  several  days.  Still  more  important,  however,  are 
those  paroxysms  of  mania  immediately  following  the  convulsive  attacks, 
which  manifest  themselves  by  such  a  degree  of  blind  fury  and  violence, 
such  wild  gesticulation,  as  scarcely  ever  occui's  in  ordinary  mania.  In 
other  cases,  states  of  profound  melancholia,  sometimes  calm,  sometimes 
agitated,  and  in  the  latter  case  sometimes  amounting  to  actual  mania,  break 
out  after  the  attack.  In  general,  all  these  states  rapidly  pass  off,  particu- 
larly by  sleep;  sometimes,  however,  they  pass  into  a  condition  of  stupor,  in 
which  the  patients,  with  more  or  less  cerebral  congestion  and  fever,  lie 
completely  exhausted  and  prostrated,  and  may  at  last  sink,  in  the  course 
of  a  few  days,  or  it  may  be  weeks,  under  a  condition  presenting  indefinite 
typhoid-like  symptoms  (with  negative  post-mortem  results). 

Precisely  similar  intellectual  derangements  may  also  occur  without 
having  been  preceded  by  convulsive  attacks,  or,  to  a  certain  degree,  in 
their  stead.  Then  these  always  occur  several  times  in  succession,  and 
there  is  thus  originated  an  intermittent  mania  of  the  most  serious  descrip- 
tion, alternating  with  epileptic  attacks. 

But  a  very  great  number  of  epileptics  are  in  a  state  of  chronic  mental 
disease  even  during  the  intervals  between  the  attacks.  In  order  to  appre- 
ciate to  what  extent  this  is  the  case,  we  must  not  confine  ourselves  to  the 
isolated  cases  met  with  in  private  practice,  but  we  must  study  the  ques- 
tion in  the  light  of  the  results  furnished  by  observations  conducted  in 
large  asylums  devoted  to  such  patients.  Thus,  amongst  385  epileptic 
women  observed  by  Esquirol,'  there  were  46  hysterical,  of  whom  many 
suffered  from  hypochondria  and  maniacal  attacks;  30  others  were  maniacs; 
12  were  monomaniacs;  8  were  idiots;  145  were  dements  (of  these  16  were 
constantly  so — the  others  for  only  a  shorter  or  longer  time  after  the 
attack);  50  were  Aveak  in  memory  or  had  exalted  ideas.  Sixty  (only  |th) 
were  free  from  intellectual  derangement;  but  nearly  all  of  these  were 
irritable,  iieculiar,  and  easily  enraged.  The  latter  trait  of  character — a 
dominant,  suspicious,  discontented,  misanthropic  perversion  of  sentiment, 
sometimes  even  actual  melancholia  with  suicidal  tendency*— is  observed 
in  a  great  many  epileptics.  This  may,  in  great  degree,  originate  from 
the  sense  of  their  sad  and  exceptional  position,  from  the  gradual  percep- 
tion of  the  moral  death  to  which  their  malady  condemns  them. 

The  most  important  persistent  psychical  disorder  to  which  epileptics 
are  subject  is  dementia.  As  a  rule,  it  makes  its  appearance  earlier 
according  to  the  frequency  of  the  attacks.  Memory  fails;  perception 
becomes  dull;  the  imagination  loses  its  brilliancy;  its  genuineness  and  fer- 
vor, and  the  emotions  become  withered.  The  physiognomy  and  deport- 
ment change — the  patient  becomes  thick-lipped,  coarse  in  his  features 
and  repulsive  in  his  appearance.  As  the  attacks  become  weaker  and  less 
frequent,  the  mental  faculties  may  regain  their  power,  but,  owing  to  the 
rarity  of  radical  cure  in  epilepsy,  the  majority  of  these  patients  finally 
fall  into  dementia. 

The  existence  of  these  intermittent  convulsive  forms  in  the  insane  is, 

'  Zeitschrift  fiir  Anthropologie,'  1825,  i.,  p.  190.     The  dissertation  on  epilepsy  by 
Dr.  C.  F.  Horing,  T    bingen,  1859,  contains  many  observations  of  this  kind. 
■  'Maladies  Mentales,'  vol.  i 


IMPORTANT    COMPLICATIONS    OF    INSANITY.  287 

therefore,  of  very  great  importance  in  regard  to  the  prognosis.  Demen- 
tia with  epilepsy  may  be  considered  as  perfectly  incurable;  and  in  other 
forms  of  insanity  complicated  with  epilepsy,  recovery  is  altogether  excep- 
tional. Some  asylums,  therefore,  which  are  exclusively  devoted  to  curable 
cases  of  insanity,  shut  their  gates  against  all  insane  persons  who  are 
affected  with  epilepsy. 

The  psychical  derangements  observed  in  epilepsy  are  not  nearly  so  peculiar  as 
those  in  general  paralysis;  these  may  assume  various  forms,  which,  however, 
all  terminate  in  states  of  mental  weakness.  Muscular  paralysis  occasionally  oc- 
curs in  the  epileptic  insane,  but  it  does  not  commence  in  the  tongue  and  lips,  and 
is  very  frequently  confined  to  one  half  of  the  body;  the  accompanying  delirium 
is  not  the  same  as  in  general  paralysis.  For  insanity  complicated  with  epilepsy, 
see  the  recent  works  on  the  latter  disease,  especially  that  of  Delasiauve  (Paris, 
1854);  Flemming,  'Psychosen,'  p.  118;  Haushalter,  '  Du  Delire  epileptique,'  Diss., 
Strasb.,  1853;  Weyers,  ibid.,  1857;  Cossy,  '  Rech.  sur  le  Delire  aigue  des  Epilep- 
tiques,'  Paris,  1854. 

§  180.  Many  other  morbid  appeararices  in  the  motory  nervous  system 
may  also  complicate  insanity.  Sometimes  transitory  general  convulsive 
states  resembling  hysterical  attacks,  or  proceeding  from  great  cerebral 
congestion  or  acute  meningitis;  sometimes  chronic  general  convulsive 
forms,  chorea-like  movements,  turning  round  and  round,  walking  back- 
wards or  in  a  circle,  and  the  like;  sometimes  chronic  convulsions  re- 
stricted to  certain  muscles, — for  example,  constant  convulsive  nodding  of 
the  head,  convulsive  lifting  of  the  leg  when  walking,  etc. ;  sometimes  con- 
tractions of  certain  groups  of  muscles  (of  the  extremities,  strabismus), 
with  or  without  paralysis  succeeding.  We  have  already  sj)oken  of  these 
(§  62),  and  of  their  unfavorable  prognostic  significance. 

Of  quite  as  serious  significance  are  those  vague  neuralgias — hitherto 
too  little  considei'ed — which  are  observed  in  all  parts  of  the  organism  as 
fleeting  pains,  and,  not  unfrequently,  at  the  period  of  transition  of  the 
disease  to  an  incurable  state  of  weakness.  The  fact  of  their  frequency 
under  such  cn-cumstances  warrants  us  in  considering  them  as  of  central 
origin,  and  as  intimately  connected  with  the  insanity,  and  especially  with 
the  persistent  organic  changes  within  the  cranium,  which  ordinarily  take 
place  at  this  period.  They  are  often  closely  connected  with  those  slight 
cutaneous  neuralgias  which  give  rise  to  ideas  of  being  electrified,  and  by 
no  means  ought  these  to  be  discarded  under  the  excuse  of  "rheumatic 
pains." 

Finally,  the  group  of  febrile  symptoms  which  so  frequently  accompany 
the  first  appearance  of  the  insanity  may  be  mentioned  as  a  common  com- 
I^lication,  and  one  intimately  connected  with  the  disease  of  the  brain. 
Eigors,  heat,  exhaustion,  pains  in  the  limbs,  thirst,  foul  tongue;  dis- 
ordered appetite,  bowels,  and  urinary  secretion;  epigastric  tenderness, 
dryness  of  the  skin,  rapid  emaciation — occur  very  frequently  at  the  period 
when  the  symptoms  of  the  cerebral  disease  begin  to  be  manifested.  Gen- 
erally they  disappear  spontaneously  or  under  the  use  of  simple  remedies 
in  the  course  of  a  few  weeks,  or  even  days,  and  the  insanity  continues  its 
course — with  certain  exceptions' — without  fever.  Not  unfrequently 
these  states,  on  account  of  the  still  slightly  prominent  cerebral  symptoms, 
are  regarded  as  gastric,  rheumatic,  catarrhal  fever,  which  preceded  the 
development  of  the  mental  disease,  out  of  which  this  has  "developed" 
itself  from  want  of  a  crisis.     Or  the  foul  tongue,  loss  of  appetite,  and 

»  See  8  63. 


288  IMPORTANT    COMPLICATIONS    OF    INSANITY. 

constipation  are  regardea  as  symptoms  of  some  serious  abdominal  disease 
which  is  now  termed  the  cause  of  the  insanity.  In  such  cases,  an  unbiased 
observation  and  physiological  analysis  of  the  symptoms,  and  their  analogy 
with  those  of  other  cerebral  diseases,  will  generally  suffice  to  enable  us  to 
avert  such  errors. 


fATHOLUGiUA-L,   AJSATOMY    Oh    >1£JMTAL    DISEASE.  289 


BOOK  FOUETH. 

THE  PATHOLOGICAL  ANATOMY  OF  MENTAL  DISEASE. 


§  181.  Whoever  attends  not  merely  to  the  symptoms  of  disease,  but 
also  to  the  abnormal  organic  conditions  from  which  these  symptoms 
spring,  will  readily  admit  that  in  insanity  the  observation  of  post-mortem 
appearances  is  a  department  of  psychology  of  the  utmost  importance. 
Here,  in  pathological  anatomy,  do  we  find  a  full  answer  to  the  question, 
WJiat  are  the  special  diseases  the  symptoms  of  which  we  have  previously 
become  acquainted  with  either  by  themselves  individually,  or  in  combi- 
nation with  certain  forms  of  disease?  Here,  also,  is  to  be  found  the  basis 
of  a  true  diagnosis — that  is,  an  anatomical  diagnosis.  To  us  post-mortem 
examinations  are  not  mere  employments  from  which  we  seek,  after  the 
death  of  the  patient,  to  gratify  an  idle  curiosity.  We  do  not  consider 
pathological  anatomy  in  the  light  of  a  mere  collection  of  curious  facts, 
as  a  dry  register  of  observed  anomalies.  We  have  not  only  to  consider 
the  presence  or  absence  of  such  alterations  generally,  not  only  to  establish 
their  intimate  connection  with  the  morbid  cause  through  which  that  dis- 
covered after  death  first  originated,  and  to  employ  them  for  the  preserva- 
tion and  treatment  of  living  patients;  we  have  also  to  consider  whether 
a  careful  examination  of  pathological  and  anatomical  facts  will  not  assist 
us  in  forming  conclusions  of  a  still  more  comprehensive  nature,  and 
whether  definite  fundamental  facts  cannot  be  elicited  which  might  throw 
a  clearer  light  on  the  intimate  nature,  on  the  mode  of  progression  of 
these  diseases,  as  well  as  upon  the  wliole  physiology  and  patliology  of  the 
brain.  If  we  do  not  deceive  ourselves,  this  department  of  our  subject 
has  not  been  without  such  results. 
19 


290  PATHOLOGICAL   ANATOMY    OF   THE   BRAIN. 


CHAPTEK  I. 

PATHOLOGICAL  ANATOMY  OF  THE  BRAIN  AND  ITS  MEMBRANES. 

§  182.  The  anatomical  changes  which  indicate  insanity,  that  is,, 
which  produce  psychical  anomalies  during  life,  are  naturally  to  be  sought 
for  within  the  cranium — in  the  brain  and  its  membranes.  According  to 
the  data  which  we  at  present  possess,  it  is  a  well-constituted  fact,  that  in 
the  bodies  of  many  persons  who  have  been  insane  no  anomalies  in  these 
parts  are  to  be  found.  If  we  examine  the  great  mass  of  uncertain  records, 
and  except  the  cases  in  which  the  insanity  was  cured  before  death,  there 
still  remains  a  number  of  cases,  reported  by  careful  special  observers  (and 
which  may  easily  be  confirmed  in  any  asylum),  where  the  cranial  cavity 
and  its  entire  contents  presented  altogether  normal  relations. 

We  ought  to  be  quite  as  grateful  to  pathological  anatomy  for  the  con- 
firmation of  this  fact,  as  for  the  discovery  of  anatomical  lesions.  For 
although  in  all  cases  of  insanity  we  must  assume  a  pathological  affection 
of  the  brain,  there  is  thus  presented  to  us  by  these  negative  results,  on 
the  one  hand,  the  strong  analogy  of  cerebral  disorders  without  anatomical 
changes  to  many  affections  of  the  spinal  and  peripheral  nerves,  in  which 
there  is  likewise  no  anatomical  lesion  of  the  tissue;  and,  on  the  other 
hand,  we  thereby  obtain  trustworthy  data  for  our  prognosis  and  treat- 
ment. 

But,  in  order  that  we  may  not  form  false  conclusions  from  the  fact 
that  cases  exist  where  no  anatomical  changes  are  present,  it  must  be 
particularly  borne  in  mind  that,  according  to  the  statistics  of  recent  care- 
ful observers,  these  cases  always  constitute  the  minority.  We  must  esti- 
mate their  numbers,  not  by  the  statements  of  those  physicians  who, 
though  perhaps  excellent  administrators  or  theorists,  have  had  no  oppor- 
tunity of  studying  the  structure  of  the  brain  and  its  pathological 
changes — who  understand  merely  how  to  make  a  rough  section  of  the 
brain  with  scalpel  and  forceps,  and,  of  course,  constantly  find  nothing.. 
We  must  consider  how  easily  many  very  minute  but,  nevertheless,  impor- 
tant changes — even  exclusive  of  those  which  are  only  microscopically 
appreciable — may  elude  mere  ordinary  attention,  and  we  ought,  as  a  rule, 
to  accept  statements  regarding  the  normal  or  abnormal  condition  of  the 
brain  from  those  only  who,  by  the  whole  spirit  of  their  writings,  show 
that  they  are  acquainted  with  pathological  anatomy,  that  they  acknowl- 
edge this  pre-eminently,  and  that  they  know  what  is  to  be  looked  for  and 
what  is  to  be  esteemed.  Besides,  in  more  recent  times,  the  discovery  of 
previously  unknown  changes,  and  a  more  definite  anatomical  and  logical 
investigation  of  previously  known  facts,  have  tended  greatly  to  promote 
the  patliological  anatomy  of  the  brain;  and  just  as  we  know  for  certainty 
that  much  that  is  important  was  overlooked  by  the  older  investigators,  so 
may  we  anticipate  still  greater  results  from  still  more  searching  and 
minute  investigations  in  the  future. 

Not  only  should  these  negative  results,  however,  but  even  their  theo- 
retical application  and  the  conclusions  derivable  from  them,  be  received 


PATHOLOGICAL    ANATOilY    OF    THE    BKAIN.  291 

with  favor.  We  must  be  careful  not  to  underrate  their  importance  on 
account  of  the  occasional  absence  of  anatomical  changes  after  death,  and 
to  conclude  that,  for  this  reason,  such  anatomical  lesions  when  present 
may  not  be  the  cause  of  the  mental  disorder.  That  would  be  similar  to 
reasoning  of  the  following  nature:  because  cough  and  dyspnoea  occasion- 
ally exist  witho^^t  any  anatomical  changes  in  the  lungs,  therefore  in 
I^neumonia  these  symptoms  might  not  be  the  results  of  this  pulmonary 
affection;  because  convulsions,  spasms,  paralyses,  sometimes  exist  with- 
out organic  change  in  the  spinal  cord,  therefore,  in  cases  of  inflammation 
of  the  spinal  cord,  the  convulsions,  spasms,  paralyses,  etc.,  are  not  the 
direct  results  of  this  inflammation,  but  it  is  more  probable  that  they 
have  some  other  and  unknown  cause !  Indeed,  the  mere  discovery  of  any 
abnormal  cerebral  condition  is  only  the  first  step  in  advance;  and  we 
must  not  rest  content  with  this,  or  expect  to  recognize  in  every  such 
anomaly  the  particuhir  disorder  from  which  the  individual  psychical 
anomaly  directly  springs.  A  knowledge  of  the  intimate  connection  be- 
tween kind  of  alteration  and  form  of  psychical  disease  has  not  yet  been 
arrived  at.  It  is,  however,  of  great  importance  to  discover  whether  in 
concrete  cases  palpable  indications  of  disease  exist  in  the  crania  of  the  in- 
sane, what  they  are,  what  appearances  they  bear,  and  how  their  form  in 
general  is  related  to  the  appearances  of  the  mental  affection  as  a  whole. 

The  gross  misconceptions  held  by  the  older  exclusively  psychological  or  theo- 
retical school  regarding  the  entire  anatomical  view  of  mental  diseases,  require  in 
the  present  state  of  science  no  further  refutation.  Now,  errors  and  one-sided  views 
within  the  pathological  anatomical  school  are  rather  to  be  guarded  against.  It  - 
does  not  by  any  means  follow  that  the  alterations  which  we  discover  in  the  cra- 
nium are  the  immediate  causes  of  definite  psychical  anomaUes,  of  this  or  of  that 
form  of  delirium,  or  that  the  individvul  symptoms  of  the  mental  derangement  are 
the  di7'ect  result  of  the  anatomical  lesion.  Certain  attempts  in  this  direction, 
among  others  those  of  an  eminent  German  psychologist,  are  entirely  misdirected; 
and  will  for  a  long  time  prove  fruitless.  The  already  discovered  alterations  can, 
as  yet,  only  demonstrate  that  the  brain  generally,  or,  still  more  indefinite,  that 
the  cranial  contents  are  diseased,  and  in  what  manner;  but  how  a  psychical  dis- 
order, or,  to  speak  more  plainly,  how  this  or  that  particular  form,  arises  from  this 
disease  in  the  case  of  some  particular  person,  and  not  in  other  persons,  although 
affected  by  tlie  same  alteration,  cannot  yet  be  explained  with  any  degree  of  cer- 
tainty. Doubtless,  there  exist  many  pathological  lesions  in  the  insane  which  have  ; 
no  connection  with  the  mental  disease;  in  particular,  the  various  final  processes, ' 
recent  meningitis,  softenings,  apoplexy,  etc. ;  these  are  fatal,  and  for  the  most 
part  not  accidental  complications;  and  certainly,  as  these  may  occur  acutely  and 
cause  death,  so  may  they  in  many  cases  appear  earlier,  persist,  recover  partially, 
etc.— in  short,  present  after  death  a  morbid  change  of  long  standing  which,  per- 
haps, had  very  little  connection  with  the  symptoms  of  the  mental  disorder.  To 
distinguish  and  to  decide  on  each  of  these  separately  is  the  province  of  a  critic  of 
anatomical  knowledge  and  experience.  The  anatomical  view  does  not  consist  in 
the  belief  that  every  mental  disorder  must  correspond  to  a  palpable  cerebral  lesion 
—what  must  we  expect  to  find  in  the  brain  of  one  who  dies  during  sleep?  and 
yet  sleep  is  a  change  in  the  psychical  functions  even  more  decided  than  is  ob- 
served in  any  form  of  mental  disease  \—<ihe  anatomical  method  consists  in  inves- 
tigating what,  according  to  experience,  the  post-mortem  appearances  in  the  insane 
are,  and  then,  by  comparing  these  lesions  and  the  processes  which  lie  at  their 
foundation  with  the  symptoms  observed  durmg  life,  to  arrive  at  comprehensive 
anatomical  views  in  regard  to  these  cerebral  affections.  This  doctrine  is  main- 
tained in  the  first  edition  of  tliis  work,  though  not  so  explicitly  stated. 

Another  misimderstanding,  which  we  present  need  scarcely  do  more  than 
mention,  is  this— that  the  pathological  lesions  in  the  insdne  are  merely  results  of 
the  mental  disease.  In  this  quibble  a  sort  of  last  refuge  is  sought  from  the  patho- 
logical anatomical  modes  of  viewing  matters;  any  attempt,  however,  at  earnest 
inquiry  as  to  how  the  psychical  disorder  could  have  this  result  has  never  yet  been 
made.  Consequently,  a  microcephalus  or  cerebral  defect  in  idiots  must  in  the 
end  also  be  declared  the  result  of  the  idiocy. 


( 


292  PATHOLOGICAL    ANATOMY    OF    THE    BRAIN. 

Authentic  reports  of  autopsies  in  which  the  condition  of  the  brain  is 
stated  to  be  normal  are  principally  those  of  cases  of  uncomplicated  recent 
insanity,  in  the  forms  of  melancholia  and  mania;  and,  as  a  rule,  anatomi- 
cal changes  are  frequent  in  proportion  to  the  duration  of  the  mental 
disease,  according  as  it  presented  symptoms  of  mental  weakness,  particu- 
larly of  profound  dementia,  and,  finally,  according  as  it  was  complicated 
with  paralysis.  Still,  cases  presenting  considerable  acute  anatomical 
changes  occur  as  recent  cases  of  primary  insanity  (for  example,  the  mania 
of  acute  meningitis);  and,  again,  many  reports  of  autojisies  of  cases  which 
correspond  to  chronic  cases  of  dementia  and  advanced  imbecility  show  an 
entire  absence  of  any  anatomical  anomaly.  Indeed,  even  of  the  most 
severe  mental  affection  known,  paralytic  dementia — in  which  also,  gener- 
ally speaking,  by  far  the  greatest  and  most  constant  lesions  are  found — 
there  constantly  occur  cases  where  nothing  abnormal  can  be  discovered  by 
the  methods  hitherto  in  ordinary  use.  In  the  present  state  of  science, 
such  cases  must  be  considered  either  as  rare  isolated  observations,  such 
as  occur  in  many  other  departments  of  pathology,  and  hitherto  beyond 
the  reach  of  theoretical  interpretation,  or  they  must  be  accepted  as  proofs 
of  the  fact  that  even  the  most  profound  weakness  of  the  psychical  pro- 
cesses and  of  the  motory  acts  may  occur  Avithout  change  of  texture  in 
the  brain — analogous  to  what  is  sometimes  presented  in  the  spinal  cord; 
or — and  this  is  especially  applicable  to  the  last-mentioned  case-^^we  must, 
according  to  a  well-founded  analogy,  assume,  that  as  when  the  naked  eye 
can  observe  little  or  nothing,  still  the  microscope  may  probably  reveal 
important  changes,  so  from  future  advances  in  such  methods  of  research 
still  further  results  may  with  confidence  be  expected;  certainly,  therefore, 
many  of  these  cases  ought  to  be  viewed  as  affording  only  apparently  nega- 
'^  tive  post-mortem  results. 

^  The  following  figures  may  be  cited  as  examples  of  the  great  differences  which 
exist  among  observers  in  regard  to  the  number  of  diseased  and  healthy  brains  met 
with  amongst  the  insane.  Tlie  renowned  Pinel  in  261  autopsies  found  only  68, 
Esquirol  in  277  only  77,  cases  in  which  there  were  changes  in  the  brain  (Sc.  Pinel, 
'Recherches  sur  les  Causes  physiques,' etc.,  Paris,  1826,  p.  9);  Chiarugi  in  100 
cases  found  changes  to  exist  in  95,  Parchappe  in  160  cases  of  uncompUcated  men- 
tal disease  in  152("Traite  de  la  Folie;"' Docum.  necrose.,'  Paris,  1841,  pp.46, 
141);  Webster  in  72  cases  ('  Med.-Chir.  Transactions,'  vol.  xxvi.,  1843,  and  '  Annal. 
Med.  Psych.,' Mai,  1844,  p.  445)  found  lesions  within  the  cranial  cavity  in  a?/ of 
them;  Lelut  in  20  cases  of  acute  mania  found  this  in  only  3,  and  in  chronic  mania 
and  dementia  in  more  than  one-half  of  the  cases  '  Inductions  sur  la  Valeur  des  Al- 
terations de  I'Encephale,'  Par.,  1836,  pp.  63,  76).  In  the  Vienna  Asylum,  in  171 
autopsies,  absolutely  no  abnormality  was  discovered  in  only  19  cases  ('  Wiener 
Bericht,'  1858,  p.  195);  in  Prague,  in  318  cases,  no  abnormality  of  the  brain  or  its 

.  membranes  was  discovered  in  32  cases  (R.  Fischer,  1.  c,  p.  114).  It  may,  perhaps, 
be  interesting  to  compare  with  these  the  anatomical  statistics  of  a  severe  affection 
of  the  spinal  marrow,  viz.,  tetanus.  Wallis  ('  De  Tetano  Disquis.  Arithmetica}.' 
Diss.  Hal.,  1837,  p.  24)  found,  in  a  collection  of  38  autopsies  of  persons  who  died 
of  tetanus,  evidences  of  inflammation  of  the  nerve-cells  (with  softening,  indura- 
tion, and  pigmentation)  in  14  cases;  other 41  cases  presented  inflammation  without 
degeneration  (hyperaemia);  the  remaining  13  presented  nothing  abnormal  in  the 
central  organs. 

^  §  183.  According  to  recent  investigations,  it  may  be  considered  a  well- 
!  established  fact  that  the  majority  of  post-mortem  examinations  of  the  in- 
sane show  anatomical  changes  to  exist  within  the  cranium.  But  is  there 
ever  any  specific  alteration  in  insanity?  If  by  this  we  mean  a  change 
which  everywhere,  where  generally  an  abnormal  cerebral  condition  exists, 
must  invariably  and  in  the  same  manner  be  present,  then  this  question 
must  not  only  be  answered  in  the  negative,  but  considered  as  a  priori 


PATHOLOGICAL    ANATOMY    OF    THE    BRAIN.  293 

false.  A  simple  pathological  reasoning  mnst  prove  to  ns  that  the  patho- 
logical psychical  symptoms,  differing  so  widely  amongst  themselves  which 
are  comprehended  under  the  forms  of  melancholia,  mania,  dementia,  etc., 
cannot  possibly  always  have  the  same  alteration  of  the  organ  for  their 
foundation.  It  has  never  even  been  considered  possible  that,  in  diseases 
of  the  spinal  cord,  the  very  various  symptoms  of  disordered  sensation  and 
movement  could  always  proceed  from  one  and  the  same  anatomical  lesion; 
it  must  be  quite  as  clear  that  the  various  anomalies  of  self-consciousness, 
intellect,  and  will  are  not  only  capable  of  being  excited,  but  must  be  ex- 
cited, by  very  various  diseases  of  the  organ  in  question.  On  the  other 
hand,  if  we  reverse  the  question  of  the  specialty  of  the  anatomical  lesion"^ 
the  question  becomes, — Are  there  not  anatomical  changes  with  whose  ex- 
istence it  is  always  necessary  that  a  marked  disturbance  of  the  mental 
faculties,  a  mental  disease,  should  exist?  This  must  be  answered  in  the  ^ 
affirmative.  Indeed,  there  are  certain  structural  diseases  of  the  brain 
which  always  cause  considerable  anomalies  in  the  mental  functions,  even 
insanity.  A  aiffused  inflammation  of  the  gray  substance,  extending  over 
a  number  of  convolutions,  has  never  been  observed  without  profound  men- 
tal disturbance,  extensive  meningitis  of  the  convex  surface  (in  previously 
robust  individuals),  considerable  acute  oedema  of  the  greater  hemispheres, 
rapid  bilateral  atrophy  of  the  convolutions;  a  deeply  penetrating  altera- 
tion of  the  ventricular  surface  of  any  extent  were  never  observed  without 
psychical  disturbance,  particularly  mental  weakness.  Generally  speak- 
ing, it  is  far  more  the  diffuse,  the  more  general  diseases,  involving  a  large 
portion  of  the  cerebral  substance,  or  a  great  extent  of  its  internal  or  ex- 
ternal surface,  than  the  circumscribed  localized  diseases,  which  are  found 
in  the  insane;  in  particular,  a  comparison  of  the  facts  lying  before  us  ap- 
pears decidedly  to  support  the  view,  that  the  most  important  and  most 
constant  changes  in  the  insane  consist  in  diffuse  diseases  of  the  external 
layers  of  the  cortical  substance  — that  is,  of  the  surfaces  of  the  brain  jnd 
of  the  membranes  covering  them;  and  it  would  be  justifiable,  in  many 
cases  of  insanity  which  correspond  to  palpable  changes  in  the  brain,  to 
consider  that  the  chief  and  essential  disease  is  that  of  the  per iphery^  of 
the  brain.  Many  facts  also  could  speak  in  favor  of  an  essential  participa- 
tion of  the  ventricular  surfaces;  but  this  point  is  as  yet  not  so  well  estab- 
lished. Of  the  various  sections  of  the  cortical  gray  substance  of  the  con- 
volutions, we  find  the  morbid  change  most  frequent  in  the  anterior  and 
middle  (superior)  portions  of  the  great  hemispheres;  many  surgical  obser- 
vations agree  with  this  where,  in  loss  of  substance  from  injury  of  the  an- 
terior and  superior  portions  of  the  hemispheres,  there  most  constantly  , 
resulted  aberration  and  weakness  of  the  mental  faculties.  '^ 

In  the  sequel  we  shall  first  describe  the  anatomical  changes  of  the  brain  and 
its  membranes  which  are  met  with  in  insanity.  We  shall  describe  them  individu- 
ally, according  to  an  anatomical  arrangement  as  they  appear  in  recent  researches, 
and  then  we  shall,  by  way  of  summary,  investigate  what  conditions  of  the  organs 
in  the  cranium  most  frequently  correspond  to  the  various  forms  of  insanity.  The 
older  pathological  anatomical  researches  of  Bonet  and  Morgagni,  and  the  results 
of  Haller's  historical  studies,  are  collected  by  Arnold  ('Observations,' etc.,  1788); 
the  works  also  of  Meckel,  Chiarugi,  Burdach,  Greding,  and  Portal  ought  specially 
to  be  consulted.  Parchappe  ('  Recherches  sur  I'Encephale,'  2me  Memoire,  1838) 
has  collected  the  most  important  of  the  older  and  more  recent  observations,  espe- 
cially those  of  his  own  countrymen.  We  may  also  consult  Duhr,  '  De  vitiis  qu^ 
apud  Amentes,' etc.,  Diss.,  Bonn,  1840;  Giintz,  '  De  Anat.  Pathol.  Cerebri  Vesa- 
nonim,'  Lips.,  1853;  Webster,  'Med.-Chir.  Transactions,'  1849,  vol.  xxxii,,  p.  115; 
R.  Fischer,  'Path.  Anat.  Befunde,' etc..  Lucern,  1854;  Follet,  'Ann.  Med.  Psych.,' 
Oct.,  1857,  p.  477;  Voppel,  several  valuable  papers  in  '  Giinsburg  Ztschr.,'  1856, 


294  PATHOLOGICAL    ANATOMY    OF    THE    BKAIN. 

vii.,  p.  161 

Psychiatrie 

1858),  in  many  parts 

1859. 

A.  The  Cranium. 

8  184.  The  influence  of  an  abnormal  conformation  of  the  cranium  is 
naturally  most  considerable  upon  the  brain  when  the  process  of  develop- 
ment is  still  progressing;  this  point  has  been  already  sufficiently  noticed 
(8  161).  But  it  also  appears  that  the  same  anomalies  of  the  cranium 
which,  in  their  higher  degrees,  limit  the  development  of  the  brain  and 

'  psychical  faculties,  and  lead  to  idiocy,  may,  in  their  extremely  moderate 
deo^rees,  in  which  for  a  long  time  no  special  deviation  from  normal  func- 
tion is  apparent,  likewise  prove  a  predisposing  cause  of  those  aifections 
of  the  brain  which  give  rise  to  the  symptoms  of  insanity.  It  is  true  that 
we  find  the  most  various  and  most  irregularly  formed  crania  in  individuals 
who  have  always  been  healthy  and  even  in  talented  and  intellectual  men. 
But  older  (Foville)  and  more  recent  observers  (W.  Krause,  Stalil,  Seifert, 
etc. )  distinctly  that  such  irregularities  occur  in  much  greater  proportion 
amongst  the  insane.  These  consist  of  the  forms  already  described  in  the 
chapter  on  Idiocy — the  too  small,  too  low,  and  particularly  the  too  short 
crania;  in  short,  the  various  forms  of  asymmetry  and  malformation,  espe- 
cially those  produced  by  premature  ossification  of  the  sutures,  or  unilate- 
ral or  partial  contraction  of  the  cranial  cavity,  and,  less  frequently, 
microcephalus,  owing  to  moderate  hydrops  ventriculorum  dating  from 

r  early  infancy.  It  cannot  be  said  of  any  one  of  these  malformations 
that  it  IS  especially  unfavorable;  all  seem  to  exert  a  certain  predisposing 
influence,  unless  they  are  rectified  by  compensations  {§  161).  The  opin- 
ion that  cranial  deformities  may  be  especially  the  media  of  the  hereditari- 
ness  of  mental  disease  (Stahl,  Voppel)  is  as  yet  still  hypothetical;  an 
hypothesis,  however,  deserving  the  utmost  attention  and  careful  research. 
A  special  form  of  abnormality  of  the  cranium  is  produced  by  an  artificial 
deformity,  to  which  Foville  in  particular  has  directed  attention.'  _  In 
several  provinces  of  France,  especially  JSTormandy  and  Gascogne,  it  is 
customary  to  fasten  the  head-dresses  of  newly  born  children,  by  means  of 
bandages  round  the  head,  whereby  their  heads  readily  receive  an  elon- 
gated, pointed,  cylindrical  form.  In  these  districts  inflammation  of  the 
brain  in  children,  and  insanity  in  adults,  is  unusually  common;  a  fact 
which  is  attested  by  Esquirol,  who  often  wondered  at  the  large  propor- 
tion of  insane  in  his  native  province  (Gascogne),  and  by  the  statistics  of 
the  local  asylums.     Eegarding  the  thickness  and  texttire  of  the  cranial 

,  hones,  almost  every  observer  has  noticed  the  frequency  of  anomalies  of 
the  cranium  in  this  respect.  Greding  found— concurring  with  more  re- 
cent observers — in  216  autopsies,  167  instances  of  thickening,  38  of  ab- 
normal thinness,  of  these  bones.  This  increase  in  bulk,  hyperostosis  of 
the  cranium,  is  either  associated  with  too  great  abundance  of  diploe- 
tic  substance,  or,  more  frequently,  with  great  thickness,  sclerosity,  of  the 
bone.  It  is  the  final  product  of  an  acute  increase  of  nutrition,  from 
time  to  time  repeated;  or  it  may  be  of  a  chronic  and,  to  a  certain  extent, 
inflammatory  process,  which  produces  a  successive  series  of  new  osseous 
layers.  As  the  hyperostosis  takes  place  at  the  cost  of  the  intra-cranial 
space,  and  of  the  foramina  and  fissures  through  which  the  blood- 
vessels pass  to  and  from  the  brain,  it  is  frequently  the  cause  of  disorders 

1  Foville,  '  Anatomie  du  Systeme  Nerveux,'  etc.,  i.,  Par.,  1844. 


PATHOLOGICAL    ANATOMY    OF    THE    BRAIK.  295 

of  tlie  circulation  within  the  cranium,  partial  or  general  hyperaemia  or 
aufemia;  generally  speaking,  the  changes  of  nutrition  in  the  bones  of  the 
cranium  cannot  be  without  influence  upon  the  processes  of  circulation 
and  nutrition  in  the  interior  of  the  cranium.  Considerable  thickening 
and  sclerosis  of  the  cranium  occurs,  moreover,  especially  in  dementia  and 
epilepsy;  in  the  latter  it,  as  is  well  known,  not  unfrequently  constitutes 
the  sole  (of  which  no  explanation  has  as  yet  been  given)  anomaly.  De- 
pressions resulting  from  former  injuries,  traumatic  and  syphilitic  exos- 
toses, are  also  frequently  met  with;  partial  hyperostoses,  of  the  kind  pre- 
viously mentioned,  may  also  result  from  injuries  to  the  head;  and  their 
gradual  development  corresponds  with  the  psychical  disturbance  which, 
perhaps,  appears  for  the  first  time  long  after  the  injury  has  been  in- 
flicted. ^ 

In  many  other  cases  among  the  insane,  as  also  in  epileptics,  bony  for- 
mations upon  the  internal  surface  of  the  cranium,  in  the  form  of  needles 
and  stalactites — sometimes,  also,  small  exostoses,  and  osseous  tumors 
and  plates,  external  and  internal,  on  the  cranium — indicate  an  extinct 
localized  inflammatory  process,  the  products  of  wliich  here  remain  in  an 
ossified  form;  and  the  abnormal  adhesions  of  the  dura  mater  to  the  in- 
ternal surface  of  the  skull,  sometimes  limited,  at  other  times  general, 
frequently  met  with  in  the  insane,  have  the  same  significance. 

In  the  dura  mater,  scarcely  any  change  is  ever  observed  other  than 
an  occasional  thickening,  and  an  excessive  tension  or  great  laxity,  accord- 
ing to  the  volume  and  consistence  of  its  contents.  The  pathological 
changes  upon  its  inner  surface  are  connected  with  the  so-called  parietal 
layer  of  the  arachnoid. 

Larrey  ('  Clinique,'  i.,  p.  329)  has  declared  premature  ossification  of  the  craniall 
sutures  to  be  an  important  predisposing  cause  of  melancholia  and  suicide.  At 
the  present  time  these  synostoses  are  considered  primarily  as  causes  of  deformi- 
ties of  the  cranium  and  of  contraction  of  the  cranial  cavity — and  it  is  certainly 
establishetl,  according  to  investigations  of  recent  times,  that  to  the  latter  a  cer- 
tain predisposing  influence  upon  the  origin  of  mental  diseases  is  to  be  ascribed. 
See  Virchow,  '  Gesamm.  Abhandl.,'  p.  937,  u.  a.  a.  O. ;  Stahl,  '  Ztschr.  f.  Psych.,' 
xi.,  1854,  p.  545;  xii.,  1855,  p.  559;  xvi.,  1859,  p,  1;  Seifert,  ibid.,  xi.,  1854,  p.  198; 
Ki-ause,  'Ztschr.  f.  ration.  Medicin,'  1858,  p.  73;  Voppel,  'Ztschr,  f.  Psych.,'  xiv., 
1857,  p.  175;  and  '  Archiv  der  Ges.  fiir  Psych.,' i.,  2,  1858,  p.  49.— The  statement 
of  Kasloff,  tliat  in  tlie  insane  there  is  frequently  found  a  contraction  (generally 
of  one  side  only)  of  the  jugular  foramen,  appears  to  have  no  special  value,  as  in- 
equalities of  tiiat  kind  are  frequent  in  health:  Hoffmann,  however,  declares 
(Giinsb.,  'Zeitschr.,' iii.,  p.  132)  that,  in  reality,  differences  in  size  of  tlie  fora- 
mina jugularia  are  more  frequently  met  in  the  insane  than  in  the  healthy. 
Finckelnburg  has  recently  given  the  account  of  an  interesting  case  of  insanity 
arising  from  acute  puerperal  osteomalacia  of  the  cranium  ('Ztschr.  f.  Psych.,' 
xviii.,  2,  two  cases). 

Amongst  those  remarks  upon  the  external  parts  of  the  brain,  we  have 
to  include  the  condition  of  the  great  vessels  within  the  cranium.  Rigid- 
ity with  atheroma  or  ossification  of  the  larger  arteries  has  been  observed, 
in  various  degrees,  in  numerous  autopsies  of  persons  who  have  been  in- 
sane. Comprehensive  statistics  regarding  this  occurrence  are  wanted. 
Hitchman  found,  in  94  autopsies  of  insane  females  in  Hanwell,  atheroma 
of  the  cerebral  arteries  in  37.'  A  similar  condition  may  also  be  supposed  ?> 
to  exist  in  the  capillary  arteries  too  small  for  investigation;  in  the  sethere 
is  also  frequently  observed  narrowing  of  the  calibre,  owing  to  the  develop- 
ment of  connective  tissue  in  the  arterial  walls,  fatty  degneration,  etc. ; 

'  'Zeitschrift  fiir  Psychiatrie,'  ix..  1852,  p.  124. 


296  PATHOLOGICAL    ANATOMY    OF    THE    BRAIN. 

liero  and  there,  also,  small  (microscopic)  aneurismal  or  more  general 
dilatations.  We  may  assume  the  existence  of  such  states  in  tlie  living  iu 
proportion  as  there  is  rigidity  of  the  external,  especially  of  the  temporal 
arteries;  their  significance  is  the  greater  the  earlier  the  age  at  which  it  is 
observed.  The  frequent  occurrence  of  atheroma  in  connection  with 
heart  disease,  and  its  disturbing  influence  on  the  circulatory  process,  has 
already  been  mentioned. 

Larrey  ('  Clinique,'  p.  330)  has  also  remarked  the  occurrence  of  ossification  of 
the  arteries  as  well  in  home-sickness  as  in  melancholia  (for  example,  in  his  com- 
panion in  arms,  Monge,  and  in  the  celebrated  Fourcroy,  who  both  died  melancho- 
lic). In  the  case  of  a  child  twelve  years  of  age  who  committed  suicide,  there 
was  found  calcification  of  the  cerebral  arteries  (Miiller,  'Oestr.  Med.  Jahrb.,'  1844, 
Juli,  p.  44).  Thrombosis  of  tlie  cerebral  sinuses,  occasionally  discovered  in  the 
bodies  of  the  insane  (see  R.  Fischer,  1.  c,  p.  0),  has  been  hitherto  observed  only 
as  a  final  process  in  connection  with  pyaemia  and  the  like;  accordingly,  there  is 
every  reason  to  believe  tha'3  the  processes  associated  with  this  thrombosis,  when 
more  chronic  in  their  course,  also  play  a  part  in  the  production  of  mental  disease; 
this  was,  perhaps,  the  case  in  a,  case  of  thrombosis  mentioned  in  the  Vienna  Re- 
port (1858,  p.  191).    See  p.  133. 

B.  The  Arachnoid. 

§  185.  One  of  the  most  frequent  anatomical  changes  in  mental  disease 
is  opacity,  thicketiirig,  and  hypertrophy  of  the  arachnoid.  There  is  no 
form  of  insanity  where,  if  long  continued,  this  has  not  been  observed;  it 
is  especially  frequent,  in  conjunction  with  other  more  series  lesions,  after 
paralytic  dementia.  It  may  generally  be  considered  as  the  result  of 
former  chronic  hyperaemia  and  inflammatory  stasis;  it  accordingly  occurs 
together  with  increase  of  the  Pacchionion  granulations — which  depends 
on  analogous  processes — under  all  circumstances  where  habitual  cerebral 
congestion  existed  during  life,  as  in  the  case  of  drunkr.rds,  who,  indeed, 
can  rarely  be  considered  as  mentally  healthy. 

The  products  of  former  inflammation  of  the  arachnoid  may  become 
ossified,  and  we  frequently  find  such  osseous  concretions  with  rugged 
rough  surfaces  on  the  anterior  surface  of  the  brain ;  on  the  other  hand, 
the  development  of  connective  tissue  gives  rise  to  abnormal  adhesions  to 
the  pia  mater  and  cerebral  cortical  substance,  and  to  the  dura  mater  and 
the  skull:  sometimes  there  is  a  complete  agglutination  of  all  these  mem- 
branous layers.  Fine  granulations  of  the  external  surface  of  the  arach- 
noid ,  similar  to  those  of  the  ependyma  ventriculorum,  are,  according  to 
L.  Meyer,  frequently  observed  along  with  other  important  changes — 
thickening  of  the  skull,  opacity  and  thickening  of  the  delicate  mem- 
branes, atrophy  of  the  brain,  etc. 

Hypermmia  of  the  arachnoid,  especially  in  the  form  of  ecchymosis, 
frequently  occurs  as  a  sign  of  acute  recent  morbid  processes:  the  same 
may  be  said  of  the  inflammation  of  the  actually  existing  parietal  layer  of 
the  arachnoid,  described  by  Virchow  as  pacchymeningitis  interna,  and 
which  is  accompanied  by  the  formation  of  firm  pseudo-membranes,  or 
thin,  delicate,  almost  gelatinous  structures,  interspersed  with  sanguineous 
spots  and  an  acute  growth  of  cellular  tissue.'  With  regard  to  the  con- 
tents of  the  arachnoid  cavity,  there  is  frequently  found  in  it  an  increased 
quantity  of  serous  fluid,  which  is  sometimes  the  result  of  habitual  hy- 

'  These  changes,  which  were  formerly  described,  especially  by  French  observ- 
ers (Calmeil,  Bayle,  Prus,  Aubanel,  etc.)  as  "pseudo-membranes  of  the  arach- 
noid," were  for  a  long  time  viewed  in  Germany  more  as  extravasations  of  blood 
and  the  consequences  of  this;  but  Virchow  has  again  pronounced  them  to  be  in 
great  part  actual  products  of  inflammation  (pacchymeningitis). 


PATHOLOGICAL    ANATOMY    OF    THE    BRAIN.  297 

perremia  aiul  a  varicose  state  of  the  blood-vessels,  sometimes  of  secondary 
atrophy  of  the  brain.  It  is  always  accompanied  by  thickening  of  the 
membranes  and  infiltration  of  the  pia  mater. 

Of  special  importance,  however,  are  the  frequent  and  spontaneous 
hfemorrhages  into  the  sac  of  the  arachnoid  (hgematomata)  which  have 
been  noticed  by  all  observers,  particularly  in  paralytic  dementia,  but  not 
unfrequently  after  other  states  of  weakness,  and  even  after  acute  or 
chronic  mania.  In  paralytic  dementia,  they  often  seem  to  occur  during 
the  frequent  attacks  of  cerebral  congestion  with  loss  of  consciousness  (see 
§  178).  Their  diagnosis  during  life  is,  however,  uncertain;  because,  on  the 
one  hand,  when  slight  they  pass  off  without  giving  rise  to  any  symptoms; 
and,  on  the  other  hand,  their  symptoms— those  of  compression — may  read- 
ily be  mistaken  for  those  of  atrophy  and  of  encephalitis;  and,  further, 
because  compression  of  the  brain  may  be  due  to  other  causes. 

These  extravasations  of  blood  almost  always  occur  upon  the  convex  surface  of 
the  hemispheres.  As  they  have  usually  existed  for  a  considerable  length  of  time, 
they  are  generally  found  in  a  state  of  transformation,  which  in  certain  cases  may 
lead  to  mistakes  regarding  their  true  nature. 

When  there  is  a  considerable  degree  of  extravasation,  we  observe  a  large  float- 
ing cyst  under  the  dura  mater,  firmly  adherent  to  the  membrane  previously  de- 
scribed, and  almost  free  on  the  side  in  contact  with  the  visceral  layer  of  the 
arachnoid.  From  the  borders  of  the  sac  there  often  extends  a  thin,  rust-brown 
membrane,  which  finally  terminates  in  a  thin  expansion  (Rokitansky).  The  sac 
contains  a  thick,  dark-brown,  serous  fluid;  this  becomes  clear  according  to  the 
age  of  the  extravasation.  The  presence  of  this  cyst  causes  compression  and  atro- 
phy of  the  affected  hemisphere,  with  contraction  of  the  ventricles,  increased  con- 
sistency of  the  cerebral  substance,  and  mechanical  hyperajmia  and  infiltration  of 
the  meninges.  The  organized  walls  of  the  sac  appear  to  be  capable  of  being 
formed  as  well  by  the  peripheral  layer  of  the  coagulated  fibrine  as  by  the 
fibrinous  exudation  of  an  inflammation  originating  secondarily  around  the  clot. 

It  is  otherwise  when  the  amount  of  blood  extravasated  is  inconsiderable. 
These  small  extravasations,  after  absorption  of  the  watery  portion,  leave  behind 
them  at  first  rust-brown,  then  yellow,  and  afterwards  almost  quite  colorless  laniel- 
Ise  of  coagulated  fibrin.  When  observed  while  still  recent,  they  consist  of  a  mesh- 
work  of  reddish  fibres,  sometimes  as  thin  as  those  of  a  spider's  web,  and  mixed 
with  small  accumulations  of  blood-corpuscles:  afterwards  they  become  pale. 
When  they  consist  of  several  layers,  it  is  probable  that  they  have  originated  from 
several  successive  extravasations,  the  most  recent  of  which  reveals  the  hemor- 
rhagic nature  of  the  whole.  When  the  quantity  is  small,  and  after  undergoing 
transformation,  these  extravasations  of  blood  finally  constitute  a  simple  expan- 
sion upon  the  mternal  aspect  of  the  dura  mater,  which  may  be  easily  overlooked 
or  erroneously  considered  to  be  an  inflammatory  exudation. 

In  consequence  of  the  work  of  Virchow  (' Wiirzb.  Verhandlungen,'  1857,  ii.,  p. 
134),  which  moreover  was  preceded  by  J.  Hoffmann's  (Gilnsburg,  'Ztschr.,' 
iv,,  1853,  p.  176)  assumption  that  in  these  hemorrhages  we  have  essentially 
to  do  with  hemorrhagic  inflammations,  our  ideas  in  regard  to  these  extravasa- 
tions have  been  modified,  inasmuch  as  it  is  now  assumed  that  these  ordinarily 
occur  between  the  layers  and  meshes  of  the  product  of  previous  pacchymeningi- 
tis  (pseudo-membranes,  newly  formed  cellular  tissue),  the  blood  comes  from  the 
newly- formed  vessels  of  the  latter,  and  therefore  these  hemorrhages  generally 
presuppose  the  existence  of  a  former  inflammatory  process.  These  processes  can- 
not be  considered  as  primary  fundamental  disorders  of  insanity  (although  in  ex- 
ceptional cases  this  may  occur;  see  '  Wiener  Bericht,'  1858,  pp.  49-51);  they  occur 
much  more  frequently  in  the  course  of  already  existing  mental  disease:  the  larger 
hsematomata  which  compress  the  brain  may,  however,  considerably  aggravate  the 
symptoms  of  mental  weakness. 

Hemorrhage  occurring  beneath  the  arachnoid  is  quite  a  different  and  much  more 
rare  process;  it  has  no  special  significance  in  mental  disease  (being  generally 
traumatic,  or  consecutive  in  general  hemorrhagic  diathesis,  etc.).  Here  the  hem- 
orrhage is  from  the  pia  mater,  in  which  ecchymotic  patches  are  observed ;  the 
blood  may  extend  with  the  cerebro-spinal  fluid  into  the  ventricles  and  vertebral 
canal. 


\ 

V 


298  PATHOLOGICAL    ANATOMY    OF    THE    BRAIN. 

c.   The  Pia  mater  and  Surface  of  the  Brain. 

§  ]  86.  The  pathological  conditions  of  the  pia  mater  and  of  the  sur- 
face of  the  brain  are  so  intimately  connected,  that  it  is  necessary  to  con- 
sider then  simultaneously. 
y  Hypermmia  of  the  pia  mater  (and  also,  in  a  greater  or  less  degree,  of 
'  the  contiguous  cerebral  surface)  is  frequently  met  within  autopsies  of  the 
insane.  Its  pathological  significance  has  been  greatly  over-estimated,  as 
in  the  first  edition  of  this  work.  Slight  injection  of  the  vessels,  and 
many  states  merely  connected  with  the  form  of  death,  have  been  considered 
pathological;  but,  exclusive  of  these,  there  are  many  cases  in  which,  from 
the  changes  found  after  death,  increased  fulness  of  the  vessels  during 
life  is  to  be  assumed,  and  to  this,  therefore,  a  certain  connection  with 
the  morbid  state  is  to  be  ascribed.  We  must  here  distinguish  the  follow- 
ing two  principal  cases: — 

A  high  degree  of  hypersemia  of  the  pia  mater  and  surface  of  the  brain 
may  exist  as  an  acute  or  sub-acute  condition,  especially  in  violent  mania, 
proving  rapidly  fatal;  it  appears  as  a  very  intejise,  uniform  injection  of 
the  smallest  vessels  with  small  stellate  ecchymoses;this  maybe  so  intense, 
that,  having  regard  to  the  final  symptoms  of  the  disease,  to  it  may  be  at- 
tributed the  fatal  issue  (apoplexia  vascularis):  there  is  frequently  con- 
nected with  it  a  slight  red  softening  of  the  cortical  substance.  Such  states 
are  observed  especially  after  the  violent  maniacal  excitement  of  acute 
delirium  (§  138);  and  should  they  not  constitute  the  sole  pathological 
lesion  in  this  form,  they  at  all  events  play  an  important  part  in  its  produc- 
tion. The  existence  of  this  hyper^emia  during  life  is  demonstrated,  on 
the  one  hand:  by  the' changes  in  the  cortical  substance  of  the  brain,  and, 
on  the  other  hand,  by  the  symptoms,  which  are  fr^^quently  very  marked, 
of  cerebral  congestion.  The  mechanism  of  its  production  is,  at  present 
— as  of  "active"  hyperaemia  m  general — unknown.  In  the  cortical  gray 
substance,  this  hyperaemia  frequently  presents  itself  as  a  red  coloration  of 
of  various  shades,  attaining  sometimes,  in  very  acute  cases,  the  dark-red 
hue  of  erysipelas  (Foville),  or  as  a  spotted,  variegated,  striated  coloration, 
with  various  dark-red  spots  (small  extravasations  of  blood).  At  the  com- 
mencement there  is,  at  the  same  time,  increase  in  volume  and  in  consist- 
ence of  the  cortical  substance.  This  hypersemia  may  easily  pass  into 
actual  inflammation. 

A  very  difierent,  and  to  a  certain  extent  completely  opposite,  kind  of 
congestion,  more  connected  with  the  finer  and  larger  veins,  is  due  to  a 
varicose  state  and  abnormal  formation  of  sinuses  of  these  vessels;  there  is 
at  the  same  time  thickening  and  a3dema  of  the  delicate  membranes.  This 
form  is  altogether  chronic  in  its  course,  and  is  frequently  associated  with 
a  greater  or  lesser  degree  of  atrophy  of  the  brain  ("ex  vacuo");  but  it  may 
be  also  procured  by  heart-disease,  pulmonary  affections — perhaps  func- 
tional disturbances  in  the  circulatory  and  respiratory  functions,  contrac- 
tions of  foramina,  etc. ;  in  short,  from  mechanical  causes  which  impede 
the  venous  return.  The  significance  of  these  hyperaemias,  especially  of 
that  originating  ex  vacuo,  is  naturally  not  very  great:  the  mechanical  ve- 
nous stases,  on  the  contrary,  always  exert,  in  individuals  predisj^osed,  a 
certain  influence  upon  the  development  and  form  of  the  disease. 

Ekker  ('  De  Cereb.  et  Med.  Spin.  Syst.  Vas.,'  Traject.,  1853)  has  made  compar- 
ative miscroscopic  measurements  of  the  smaller  blood-vessels  and  capillaries  of 
the  cortical  substance  in  mania,  in  dementia,  and  in  health,  and  finds  that  in 
niania  they  are  considerably  dilated.  Ramaer  found  this  to  be  the  case  with  re- 
gard to  the  pia  mater. 


PATHOLOGICAL    ANATOMY    OF    THE    BRALN.  299 

Ancpmia  of  the  pia  mater  and  cortical  substance,  wliicli  is  sometimes 
met  with  in  acute  and  chronic  conditions  as  remarkable  pallor  of  the 
cranial  contents,  merits,  under  certain  circumstance  (deduced  from  the 
clinical  observations  of  the  case),  great  consideration.  It  may  be  a  co- 
symptom  of  general  anaemia.  The  great  influence  which  this  state  of  the 
blood  exercises,  especially  in  females,  and  when  acute  in  its  origin,  upon 
the  development  of  the  most  varied  nervous  and  psychical  anomalies,  is 
well  known;  and  it  is  also  admitted  that  all  sorts  of  symptoms  of  irrita- 
tion or  ot  torpidity  of  the  central  organs  may  originate  from  this  source 
alone.  We  cannot  speak  so  positively  regarding  the  cause  and  symptoms 
of  anaemia  limited  to  the  brain:  contraction  of  the  small  arteries  through 
atheromatous  processes  may  occasionally  be  assumed  as  the  cause  of  spe- 
cial anaemia.  We  must  always  consider  that  there  is  connected  with  this 
an  insufficient  and  abnormal  nutrition  of  the  brain.  When  the  anaemic 
state  is  developed  slowly,  and  its  course  chronic,  it  appears  principally  to 
give  rise  to  states  of  intellectual  weakness  and  dementia. 

As  the  final  result  of  chronic  hypersemia  ex  vacuo,  and  from  mechani- 
cal causes,  we  observe  chronic  opacity  and  serous  infiltration — oedema  of 
the  pia  mater.  This  oedema  is  extremely  frequent,  especially  after  chro- 
nic mental  disorders  (for  example,  in  the  Vienna  asylums  in  more  than 
50  per  cent),  and  principally  after  the  secondary  forms  with  well-marked 
mental  weakness.  It  frequently  occurs,  therefore,  in  connection  with 
atrophy  of  the  brain,  chronic  hydrocephalus,  oedema  of  the  brain,  colora- 
tion of  the  cortical  gray  substance,  rigidity  of  the  arteries,  etc., — in  short, 
with  states  of  marasmvis  of  the  brain, — and  appears  to  be  of  much  less 
significance  in  the  origin  and  form  of  the  psychical  anomalies  than  the 
marasmus  itself. 

§  187.  Inflammation  prope?'  of  the  pia  mater  produces  sometimes 
merely  a  more  or  a  less  rapid  thickening  of  the  membranes,  together  with 
adhesion  of  these  to  each  other.  In  the  cortical  gray  substance,  how- 
ever, the  ordinary  result  of  inflammation  in  the  nervous  tissue  is  soften- 
ing, sometimes  the  secondary  transformations  of  the  softened  tissue,  and 
in  both  together  the  important  «f//!e5^o/i  o/Z/ie  pia  mater  to  the  surface 
of  the  hrain.  These  consequences  of  meningo-cerebritis  are  ordinary 
conditions  in  the  latter  periods  of  certain  forms  of  insanity.  -..^ 

Eecent  conditions  of  this  kind  rarely  occur  after  states  of  depression,  i 
more  frequently  after  acute  mania  (see  §  186).  Thus  we  frequently  find, 
after  sudden  death  in  acute  mania,  intense  hypera^mia  of  the  cortical 
substance,  particularly  of  its  middle  layers,  with  (inflammatory)  wine  or 
violet-colored  softening  or  sponginess  of  the  tissue,  which,  if  the  patient 
continues  to  live,  undergoes  a  still  more  profound  alteration — viz.,  hard- 
ening and  atrophy  of  the  tissue, — dementia  being  the  result. 

These  inflammatory  softenings  of  the  gray  substance  are  sometimes 
Yery  difficult  to  recognize,  when  they  occur  with  very  little  red  coloration, 
where  the  sole  symptom  of  the  inflammation  is  simple  softening  of  the 
cerebral  substance  to  a  uniform  pulp.  Many  observers  have  found  the 
various  layers  of  the  gray  cortex  separately  diseased:  Sc.  Pinel,  redness  of 
the  middle  layer  in  mania;  Baillarger,  redness  of  the  inner  aspect  of  the 
four  internal  layers,  or  of  the  three  gray  strata.'  Most  frequently  the 
inflammation  is  of  the  most  superficial  layers,  combined  with  that  of  the 
pia  mater;  the  membrane  adherent  to  the  cortical  substance  takes  with  it, 

'  "  Recherches  sur  la  Couche  corticale."etc.,  '  Mem.  de  TAcad.  de  Medecine,' 
1840,  p.  172. 


300  PATHOLOGICAL    ANATOMY    OF    THE    BRAIN. 

when  detached,  the  superficial  layers  which  are  adherent  to  it,  so  that 
an  uneven,  bloody,  torn  surface  remains.  Although  this  adhesion 
and  superficial  softening,  which  particularly  affects  the  convolutions 
of  the  superior  convex  and  internal  contiguous  surfaces  of  the  hemi- 
spheres, or  even  the  Ammonshorn,  occurs  now  and  again  in  simple  chro- 
nic insanity,  particularly  in  the  secondary  states  of  weakness,  in  the 
mental  disorders  of  the  drunkard  and  epileptic,  still  it  is  by  far  most  fre- 
quent in  paralytic  dementia,  and  constitutes  one  of  the  most  important 
organic  elements  of  this  affection.  Calmeil  found  it  to  be  the  most  fre- 
quent and  most  constant  lesion  in  general  paralysis;  and  Parchappe,'  in 
eighty-six  cases,  never  saw  profound  and  extensive  softening  of  the  cortical 
substance,  especially  of  its  middle  layer,  absent;  and  the  pia  mater  was 
adherent  to  it  in  all  but  nine  cases:  in  Vienna,  again,  this  occurred  in 
not  quite  half  of  the  cases  of  paralytic  dementia.''  These  inflammatory 
softenings,  here,  as  in  other  nerve-tissue,  afterwards  pass  into  a  state  of 
atropliy  and  induration.  It  is  alwa)'s  the  most  superficial  layer  which 
first  becomes  atrophied  and  indurated,  and  as  a  callous,  thickened  mem- 
brane, adheres  to  the  likewise  dense  and  tendinous  pia  mater;  the  atro- 
phied tissue  soon  becomes  remarkably  pale,  and  it  is  always  in  the  most 
external  layer  that  it  is  most  strongly  marked.  In  the  middle  layers  the 
softening  still  continues,  and  the  superficial  layers  may  now  be  pulled  off 
as  a  coherent,  somewhat  consistent  membrane,  leaving  behind  an  uneven, 
pulpy  surface,  like  that  of  a  roasted  apple  when  the  skin  is  peeled  off. 
Should  the  middle  layer  be  only  moderately  softened,  we  may  be  led  to 
the  erroneous  conclusion  that  no  softening  exists,  if  we  do  not  take 
the  induration  into  account,  remembering  that  it  originally  arises  from 
softening;  the  atrophy  of  the  cortical  substance  through  this  kind  of 
shrivelling — analogous  to  the  shrivelling  of  other  parts  after  inflamma- 
tion (cicatricial  tissue) — may  be  so  considerable  as  to  reduce  it  to  an 
extremely  thin  layer,  and  it  may  even  seem  to  have  completely  dis- 
appeared. 

All  these  disorders  in  which,  according  to  the  microscopic  investiga- 
tions of  Rokitansky  and  other  observers,  increase  of  cellular  tissue  in  the 
gray  substance  is  the  principal  result  of  the  inflammation,  are,  as  we 
have  before  remarked,  associated  with  dementia,  and  in  particular  with 
paralytic  dementia. 

D.   Tlie  Cerebral  Substance. 

§  188.  Volume  and  consistence  of  the  brain. — In  certain  cases  we  find 
in  insanity,  as  well  as  in  epilepsy,  hypertrophy  of  the  brain.  In  such 
cases,  the  skullcap,  after  having  been  removed,  cannot  be  replaced;  the 
membranes  are  thin  and  dry,  the  ventricles  small,  and  the  convolutions 
flattened.  Sc.  PineF  states  that  he  has  several  times  met  with  conditions 
of  this  kind  after  paralytic  dementia — increase  of  cerebral  substance, 
with  atrophy  of  the  cortical  gray  substance;  a  statement  which,  as  yet, 

1  L.  c,  p.  249. 

^  '  Wiener  Bericht.,  1858,  p.  237.  This  statement  is  worth  inentioning,  as  op- 
posed to  the  opinion  that  chronic  meningitis  (often  with  inflammation  of  the 
cortical  substance)  always  lies  at  the  foundation  of  paralytic  dementia,  or,  to  use 
a  better  expression,  of  the  paralytic  mental  disorders.  Bayle,  in  1855,  thirty 
years  after  the  publication  of  his  first  work,  returned  to  the  opinion  which  lie 
then  held,  viz.,  that  this  was  the  case;  Duchek  and  L.  Meyer  suppose  meningitis 
to  be  the  principal  cause  of  the  maniacal  excitement  in  pai'alytic  monomania. 

3  'Path.  Cerebr.,'p.  369. 


PATHOLOGICAL    ANATOMY    OF    THE    BRAIN.  301 

stands  so  isolated  that  little  value  can  be  attached  to  it.  The  acute,  dry- 
swelling  of  the  cerebral  substance,  which  frequently  occurs  as  an  im- 
portant epiphenomenon  at  the  termination  of  many  other  cerebral  dis- 
eases (softening,  tumors,  etc.),  is  associated  with  anaemia  of  the  brain 
and  its  membranes,  and  in  the  present  state  of  our  knowledge  may  be 
regarded  as  a  peculiar  acute  hypertrophy,  is,  from  its  nature,  very  rare 
after  mental  disturbances,  and  has  no  connection  whatever  with  these 
affections. 

An  important  lesion,  and  one  which  is  frequently  met  with  in  the 
insane,  is  atrophy  of  the  train — sometimes  of  the  convolution,  some- 
times of  the  entire  cerebral  mass.  It  may  appear  primarily  as  senile  or 
premature  marasmus  of  the  brain;  and  it  is  then  the  fundamental  cause 
of  an  insanity  which,  from  the  first,  has  the  character  of  mental  weakness. 
Or  in  the  convolutions,  especially  in  the  cortical  substance,  it  may  be  the 
result  of  former  structural  disease,  of  inflammation,  of  prolonged 
hyperaBmia,  or  of  compression,  owing  to  an  extravasation  or  exudation, 
just  as  the  apex  of  the  lung  becomes  atrophied  when  compressed  by  a 
false  membrane,  or  the  heart  under  the  influence  of  a  strong  pericarditic 
exudation  (through  compression  and  destruction  of  the  capillary  system) . 

The  convolutions  are  thinner  than  in  the  normal  state;  but  not 
iinfrequently  the  atrophy  takes  place  unequally,  so  that  their  surface, 
especially  in  the  anterior  portion  of  the  hemispheres,  is  uneven.  The 
gray  substance,  in  particular,  is  considerably  reduced  in  volume,  and  of 
a  brown  or  wine  color,  sometimes  more  incompact  than  in  health,  but 
more  frequently  it  is  hard  and  shrivelled.  The  white  substance  is  often 
of  a  dirty-white  color,  very  tough,  and  crumples  up  when  cut;  occasion- 
ally it  presents  that  porous  form,  that  cribriform  aspect,  which  is  seen 
in  the  substantia  perforata  of  the  normal  brain,  and  which  is  the  result 
of  chronic  congestion  and  dilatation  of  the  cerebral  vessels  in  the 
atrophied  organ  (etat  crible).  Here  the  cellular  tissue  presents  that 
special  increase  discovered  by  Rokitansky:  the  originally  soft  cellular 
tissue  becomes  indurated  and  retracted,  and  takes  the  place  of  the  nerve 
elements  which  have  disappeared;  colloid  masses,  so-called  corpora 
amylacea,  occur;  the  nerve-tubes  are  destroyed,  shrivelled,  etc.  The 
vacant  space  in  the  cranium  is  occupied  partly  by  hypertrophy  of  the  bones, 
partly  by  thickening  of  the  membranes,  especially  by  oedema  of  the  pia 
mater,  which  sometimes  lies  over  an  atrophied  convolution  like  a  floating 
sac,  or  by  effusion  of  fluid  into  the  cavity  of  the  arachnoid;  partly  also 
by  dilatation  of  the  ventricles,  which  become  filled  with  fluid.  The 
vacuum  sometimes  even  gives  rise  to  sanguineous  effusions — certain 
apoplexies  of  the  arachnoid  may  be  due  to  this  cause. 

These  general  or  circumscribed  atrophies  are  frequently  observed  as 
the  fundamental  lesion  in  secondary  dementia,  after  former  states  of  ex- 
altation, after  repeated  attacks  of  delirium  tremens,  etc.  In  122  cases 
of  chronic  insanity  observed  by  Parchappe,'  there  was  a  notable  diminu- 
tion in  the  convolutions  in  more  than  one-half;  in  38  cases  of  recent 
insanity,  this  was  observed  only  once.^  But  the  states  of  atrophy  of  the 
cortical  layer  and  of  the  entire  brain  are  especially  peculiar  to  paralytic 
dementia;  they  are  not,  however,  constant  in  this  affection,  and  the 
degree  of  the  dementia  is  not  always  in  proportion  to  that  of  the  atrophy. 

The  induration,  sclerosis  of  the  cerebral  substance,  is  essentially  an 

'  L  c,  p.  140. 

-  And  thi.3  in  a  patient  affected  for  the  third  time.     Obs.  22,  pp.  19,  50. 


302  PATHOLOGICAL    ANATOMY    OF    THE    BRAIN. 

increase  of  cellular  tissue — the  formation  of  true  connective  tissue,  and 
more  or  less  atrophy.  In  tlie  highest  degrees,  the  medullary  substance 
is  of  the  consistence  of  a  hard-boiled  egg,  and  when  cut  is  as  resistant  as 
a  piece  of  caoutchouc;  the  color  is  generally  dirty- white,  blue,  gray, 
Avithout  sanguineous  points;  and  the  fibration  is,  notwithstanding  the 
great  hardness  of  the  brain,  indistinct.  There  are  sometimes  observed  in  it 
traces  of  former  apoplexies,  with  cavities  filled  with  serum,  which  when 
cut  through  resemble  the  holes  in  a  cheese.  This  induration  corre- 
sponds entirely  to  the  various  forms  of  dementia. 

Here,  with  atrophy  of  the  brain,  would  be  the  place  to  consider  the  results 
obtained  by  weighing  the  brain.  A  priori,  we  might  imagine  that  the  weight 
would  best  show  the  diminution  in  volume.  Two  circumstances,  however,  ren- 
der the  estimation  of  results  arrived  at  in  this  way  very  difficult:  on  the  one 
hand,  the  weight  of  the  brain  varies  considerably,  even  in  healthy  individuals; 
and  on  the  other  hand,  the  specific  gravity  of  the  brain  in  diseases  appears 
occasionally  to  undergo  such  deviations  that  the  weighing  of  the  organ  must 
thereby  afford  less  useful  results.  Generally,  however,  the  entire  study  of  the 
extraordinary  and  of  the  pathological  weights  of  the  brain  is  in  a  great  measure 
confusing  and  undeserving  of  confidence  (see  R.  Wagner,  '  Nachr.  v.  d.  G.  A. 
Universitat  zu  Gottingen,'  1860,  No.  7,  No.  16).  The  general  results  at  which 
Parchappe  arrived  (1.  c,  p.  142,  and  'Comptes  rendus,'  31  Juill.,  1848)  appears  to 
me  to  be  the  most  practical,  namely,  that  an  average  moderate  diminution  of 
weight  takes  place  in  insanity  ganerally,  and  particularly  in  chronic  cases; 
he  even  considers  it  proved  that  there  is  a  gradual  diminution  in  the  weight 
of  the  brain  corresponding  to  the  progressing  diminution  of  the  intelligence. 
Further,  the  more  recent  investigations  (Skae,  'Med.-Chir.  Review,'  Jan.,  1853; 
Sankey,  'Journal  of  Psychol.  Med.,'  1855,  p.  573;  Bucknill,  'Brit,  and  For. 
Review,' Jan.,  1857)  regarding  the  mode  of  determining  the  specific  gravity  in 
certain  abnormal  states  appear  to  be  of  interest:  tlie  older  investigations  in  this 
direction  (Meckel,  1764,  Leuret  and  Mitivie.  1833)  were  entirely  without  result. 
It  must  be  admitted  that  discrepancies  exist  between  these  new  investigations, 
but  they  are  such  as  may  in  part  be  accounted  for.  While,  for  example,  Skae 
and  Sankey  consider  that  in  general  there  is  an  increase  in  the  specific  gravity  of 
the  brain  in  insanity,  Bucknill  found  an  average  lower  specific  gravity:  still  he, 
too,  found  an  increase  in  "  interstitial  albuminous  deposit  in  the  brain  "  (increase 
of  connective  tissue?);  audit  is  indeed  possible  that  the  two  other  observers 
include  many  brains  of  this  description.  According  to  Bucknill,  there  is  also  a 
kind  of  atrophy  of  the  brain  in  mental  disease  which  manifests  itself  solely  by 
diminution  of  the  specific  gravity—  a  kind  of  fatty  degeneration  of  the  cerebral 
substance  without  diminution  in  volume.  But  the  methods  hitherto  employed 
in  determining  the  specific  gravity  of  the  brain  are  so  unsatisfactory,  tliat  even 
these  statements  cannot  be  considered  conclusive;  they  rather  she w  the  necessity 
of  more  perfect  modes  of  investigation. 

§  189.  Amount  of  blood  in  the  brain.  General  hypersemia  of  the 
entire  brain  is  sometimes  observed  in  recent  cases  of  insanity;  in  its 
highest  degree  (turgescence  of  the  entire  brain,  dark-red  color  of  the 
cortical  substance,  strong  injection  of  the  pia  mater  and  arachnoid,  rosy 
hue  of  certain  portions  of  the  white  substance),  it  is  sometimes  the  cause 
of  sudden  death  in  acute  mania,  after  having  produced  apoplectiform 
collapse.  Altogether  it  is  more  rare  than  hyperaemia  limited  to  the  pia 
mater  and  cortical  substance  of  the  convex  surface  of  the  brain.  When 
the  disease  has  lasted  for  a  long  time,  and  especially  wiY/^m  the  atrophied 
brain,  the  amount  of  blood  is  generally  diminished.  We  have  already 
spoken  of  the  mode  of  production  of  cerebral  hyperaemia.  Very  often  it 
is  limited  to  certain  parts  of  the  brain;  in  the  white  substance  its  higher 
degrees  appear  as  variegated  spots  of  a  rose,  violet,  or  lilac  color,  and 
may  give  rise  to  exudations  and  inflammatory  softenings. 

The  various  observations  regarding  the  frequency  of  apoplexy  in  the 
insane  do  not  all  correspond.     Esquirol,  Georget,  Guislain,  Jacobi,  and 


PATHOLOGICAL    ANATOMY    OF    THE    BRALN,  303 

F.  Hoifmann  seldom  met  with  it;  Webster,  on  the  contrary,  found  effu- 
sion of  blood  into  the  brain  13  times  in  72  autopsies;'  1  have  seen  it 
occur  in  acute  mania.  It  is  at  least  certain  that  traces  of  former  small 
apoplectic  clots  are  by  no  means  rare;  sanguineous  apoplexy  also  may  be 
sufficient  to  produce  incurable  dementia,  by  the  destruction  of  cerebral 
substance,  the  compression,  the  subsequent  inflammation  and  induration 
of  neighboring  tissue,  which  it  entails. 

Amount  of  serum  in  the  train  (cedema  of  the  brain). — Special  atten- 
tion has  been  directed  to  oedema  of  the  brain  by  the  work  of  Etoc- 
Demazy.*  According  to  his  opinions,  which  are  also  in  part  advocated 
by  Sc.  Pinel,  we  are  led  to  consider  acute  cedema  of  the  brain  as  essential 
in  melancholia  with  stupor  and  immobility  (§  133),  and  as  the  funda- 
mental cause  of  this  entire  group  of  symptoms.  This  statement,  how- 
ever, has  not  been  confirmed:  cedema  of  the  brain  is  not  at  all  constant 
in  this  affection,  and  neither  in  mental  nor  in  general  pathology  do  we 
know  of  any  group  of  symptoms  which  is  quite  a  characteristic  of  this  af- 
fection of  the  brain.  In  mental,  as  in  other  diseases,  we  find  slight 
cedema  of  the  brain  under  the  most  various  circumstances :  in  its  higher 
degrees  it  is  sometimes  observed  after  states  of  exaltation  and  of  de- 
pression, but  especially  after  paralytic  dementia;  in  general,  it  is  asso- 
ciated with  anaemia  and  more  or  less  atrophy  of  the  brain. 

E.   The  Ventricles  and  Internal  Parts. 

§  190.  Dilatation  of  the  veiitricles  (hydrocephalus  chronicus)  is 
frequently  found  in  the  insane.  It  rarely  can  be  considered  as  having 
originated  in  infancy;  in  the  great  majority  of  cases  it  is  developed 
during  the  disease,  together  with  diminution  of  the  cerebral  mass  and 
more  or  less  disease  of  the  ventricular  surface.  Most  frequently  it  is 
merely  the  necessary  result  of  atrophy  of  the  brain.  It  is  observed, 
therefore,  after  all  forms  of  insanity  {i.  e.,  it  may  have  originated  in 
these  conditions,  even  in  states  of  depression  or  exaltation  of  sentiment), 
but  more  particularly  after  protracted  states  of  weakness,  and,  above  all, 
after  paralytic  dementia  (together  with  cedema  of  the  pia  mater,  the 
cerebral  substance,  increase  of  cellular  tissue  in  the  latter,  osteophytes, 
etc. ) :  it  is  also  frequent  in  the  insanity  of  drunkards.  In  very  few 
cases  can  it  be  considered  the  primary  process  and  fundamental  cause  of 
the  symptoms  {i.  e.,  acts  by  paralyzing  the  mental  faculties  through  the 
pressure  which  it  exerts) ;  in  general  it  is  to  be  considered  as  secondary, 
consecutive  to  atrophy  of  the  brain,  the  latter  state  being  the  essential 
pathological  lesion. 

Partial  contractions  and  shortening  of  the  ventricles,  and  adhesions 
of  their  surfaces  (particularly  in  the  posterior  and  inferior  cornua),  are 
by  no  means  rare  in  health,  but  much  more  frequent  in  insanity;  Greding, 
Esquirol,  Ferrus,  especially  Bergmann'  (in  chronic  dementia — adhesion 
of  the  posterior  cornua,  according  to  his  account,  in  several  hundred 
cases),  have  observed  these  anonalies;  and  the  latter  considered  them — 
but  incorrectly — to  be  the  special  pathological  lesions  in  chronic  demen- 

'  '  Med.-Chir.  Transactions,'  vol.  xxvi.,  1843,  p.  413,  In  his  recent  work 
(1850)  he  states  that  in  sixty-seven  post-mortem  examinations  of  patients  in 
Bethlehem  he  found  extravasation  of  blood  in  fifteen. 

5  De  laStupidite  consideree  chez  les  Alienes,'  Paris,  1833  (ten  cases  and  four 
autopsies). 

3  '  Ztschr.  f.  Psychiatrie,'  1844,  No.  2. 


304  PATHOLOGICAL    ANATOMY    OF    THE    BKAIN. 

tia.  They  may  be  regarded  as  results  of  sliglit  inflammation  of  the  epen- 
dyma,  and  as  such  have  a  certain  though  very  inconsiderable  pathological 
interest. 

In  chronic  hydrocephalus  we  generally  find  the  epeudyma  ventricula- 
rum  thickened,  covered  with  granulations,  and  of  a  leathery  consistence; 
more  rarely  the  ventricular  surface  is  covered  with  false  membranes  or 
cretaceous  plates:  the  former  are- sometimes  found  in  paralytic  dementia.' 

The  presence  of  so-called  hydatids  of  the  vascular  plexus  is  too  common  to  be 
considered  an  essential  alteration :  Devaux  found  a  free  hydatid  as  large  as  an 
acorn  in  the  right  lateral  ventricle  (with  ecchymosis  of  the  cerebral  surface)  after 
nostalgic  melancholia  with  violent  headache  (Nasse,  '  Zeitschrift  f.  Anthropolo- 
gie,'  1823,  ii.,  p.  501);  Bergmann  discovered  a  formation  of  pretty  large  crystals 
of  double  phosphate  in  both  plexus  chorioidei,  in  a  case  of  mania  with  mental 
weakness. 

Recent,  especially  white  softenings  of  the  ventricular  surfaces  occasionally 
occur  as  the  cause  of  death  in  acute  cases;  their  chronic  induration  is  sometimes 
associated  with  dilatation  of  the  ventricles  in  atrophy  of  the  brain  (paralytic  de- 
mentia). 

Regarding  the  pmeaZ  gland  (see  also  Greding,  '  Vermischte  Schrif ten,' Al ten- 
burg,  1781,  p.  18U),  Bergmann  has  already  shown,  in  his  earlier  works  (Nasse's 
'Zeitschrift  f.  Anthropol. ,'  1825,  i.,  p.  173;  Holscher's  'Annalen,'!.  c,  pp.  510, 
5a3,  529,  etc.),  that  in  autopsies  of  the  insane  we  frequently  find  considerable  tume- 
faction and  luxui'ious  growth  of  tiie  vascular  plexus  around  the  gland,  in  part  to- 
gether with  an  almost  general  hypertrophy  of  its  pia  mater,  a  border  of  granula- 
tions, an  adhesion  of  the  pineal  gland  to  the  vascular  plexus  on  the  lower  aspect 
of  the  corpus  caUosum,  and  the  like.  Subsequently  ('Zeitschrift  f.  Psychiatrie,' 
1844, 1.  c.)  this  observer  declares,  in  numerous  publications,  the  abnormal  tumefac- 
tion of  the  vascular  plexus,  displacement  and  adhesion  of  the  pineal  gland,  to  be 
one  of  the  most  constant  alterations  in  chronic  partial  dementia:  this  opmion, 
however,  does  not  appear  to  me  to  be  at  all  fotmded  on  fact. 

The  pituitary  gland  also  presents  in  insanity  as  well  as  in  epilepsy,  occasional 
examples  of  pathological  change.  Amelung  (Nasse,  '  Zeitschr.  f .  Anthropologic, ' 
1824,  p.  352)  found  it  transformed  into  thin  purulent  matter,  after  monomania 
with  fixed  ideas  and  suicidal  tendencies;  F.  Arnold  ('Bermerkungen  iiber  den 
Ban  des  Hirns  und  Riickenmai'kes,'  p.  203)  observed  suppuration  of  its  posterior 
lobule  after  general  paralysis.  In  a  maniac  in  the  Vienna  Asylum  there  was  found 
— together  with  hydrocephalus  chronicus,  oedema  meningum  et  cerebri,  and  exos- 
tosis basis  cranii — hypertrophy  of  the  gland ;  its  posterior  lobe  was  transformed 
into  a  soft  tumor  of  a  grayish-red  color,  almost  as  large  as  a  walnut,  and  filled  with 
a  creamy  fluid;  the  seUa  turcica  was  considerably  atrophied  ('Wiener  Bericht, 
1858,  p.  189). 

The  cei'ebellum  has  as  yet  received  comparatively  little  consideration;  never 
theless,  Bergmann's  observations  regarding  the  ventricular  surfaces — granulatioo 
in  the  fourth  ventricle,  etc. — refer  also  in  great  part  to  the  cerebellum,  and  S'o-  I 
ville  states  that  he  has  frequently  met  with  adhesions  in  the  pia  mater  to  its  sui'- 
face  along  with  a  certain  constancy  of  the  symptoms  during  life.  Besides,  there 
are  also  many  descriptions  of  rare  diseases  of  the  cerebellum  in  paralytic  demen« 
tia  by  Arnold,  Stolz  (' Oestreich.  Jahrbucher,'  Marz,  1844,  p.  268),  Lelut  ('Aim6 
Med.  Psychol.,'  Mai,  1844,  p.  462),  etc. 

§  191.  In  reviewing  these  anatomical  changes  in  the  brain,  it  may 
perhaps  surprise  us  that  no  mention  has  been  made  of  the  serious  de- 
generations which  result  from  the  production  of  pseudo-plastic  forma- 
tions within  the  organ  (cancer,  tumors,  upon  the  basis  cranii,  ^ibercles, 
parasites,  etc.).  In  reality  these  affections  are  rarely  met  with  in  asylums 
for  the  insane.  It  is  not  that  they  do  not  produce  serious  psychical  ano- 
malies— in  the  latter  stages  of  these  cases  states  of  mental  weakness,  and 
sometimes  even  profound  dementia,^  are  usually  jn-esent,  and  at  the  com- 

'  For  example,  Macquet,  '  Annal.  Med.  Psych.,'  Mai,  1844,  p.  464. 

'^  In  the  last  stages  of  tumors,  encephalitis,  abscess  of  the  brain,  etc.,  there  is 
frequently  such  profound  dementia  as  is  not  even  seen  in  the  lowest  grade  of 
idiocy.  These  pj,tients  occasionally  behave  as  animals  do  after  the  abstraction  or 
the  hemispheres. 


PATHOLOGICAL    ANATOMY    OF    THE    BKAIN.  305 

mencement  they  arc  frequently  accompanied  by  a  melancholic  disposition 
or  by  maniacal  excitement.  These,  however,  are  not  in  general  the  most 
striking  symptoms;  the  commencement  is  rather  characterized  by  "apo- 
plectic symptoms,'"  especially  severe  motory  disorders  (convulsions, 
paralyses,  etc.);  and  these  are  the  more  constant  according  as  the  morbid 
process  affects  the  cerebral  substance  to  only  a  certain  depth:  the  existing 
psychical  disposition,  the  loss  of  memory,  etc.,  are  merely  accessory 
symptoms — therefore  (p.  9)  the  affection  is  not  classed  amongst  mental 
diseases,  and  the  patient  is  not  sent  into  an  asylum.  In  this  relation  and 
its  immediate  consequences  lies  the  simple  explanation  of  the  apparent 
anomaly  brought  so  prominently  forward  by  the  opponents  of  the  patho- 
logical anatomical  mode  of  consideration,  viz.,  that  very  slight  anatomi- 
cal changes  of  the  brain  produce  an  effect  (insanity)  which  the  most 
serious  and  most  profound  alterations  do  not.  Nevertheless,  profound 
alterations  of  the  cerebral  substances  are  constantly  and  frequently  found 
after  death  in  the  insane. 

I  again  refer  to  the  cases  of  Stoltz  and  Lelut,  to  a  case  cited  by  Romberg  (Nasse, 
'Zeitschrift  fur  Antliropologie,'  1828,  iii.,  p.  195),  where,  after  mania  without  par- 
alysis, four  "  hydatids "  were  found  penetrating  several  lines  into  the  cortical 
substance,  together  with  pseudo-membranes  upon  the  arachnoid,  and  mentions 
the  following  cases  by  way  of  example: — In  a  melancholic  in  the  asylum  at 
Prague,  there  was  found  in  the  right  cerebral  hemisphere  a  cancerous  nodule  as 
large  as  a  hen's  egg,  together  with  opacity  and  thickening  of  the  membranes  and 
slight  chronic  hydrocephalus  (R.  Fischer,  1.  c,  p.  89);  in  a  patient  wlio,  after 
headache  and  excitement,  fell  into  dementia,  there  was  found  a  fibroid  tu- 
mor the  size  of  an  egg  in  the  centre  of  the  brain,  involving  the  septum,  fornix, 
etc.  ('Wiener  Bericht,'  p.  190);  the  point  of  a  penknife  surirounded  by  hardened 
tissue  in  the  cerebral  substance  after  dementia  with  epilepsy  (ibid.,  p.  191);  a 
sharp  osseous  concretion  in  the  fourth  ventricle,  with  oedema  of  the  membranes 
after  mania;  recent  and  old  tubercle  of  the  brain  after  dementia  and  mania 
(ibid.);  tuberculosis  of  the  pia  mater  with  encephalitis  (ibid.,  p.  212);  chronic  tu- 
berculosis of  the  brain  with  mental  disease  of  one  year's  standing  (Finkelnburg, 
Virchow's  'Arch.,'  xx.,  1861,  p.  524);  finally,  the  numerous  cases  of  cysticercus 
of  the  brain,  regarding  which  the  following  works  maybe  consulted:— Med. -Chir. 
Transact.,' vol.  xxvii.,  1844,  p.  12;  Gunsburg,  'Zeitschr.,'  i.,  p.  62;  ii.,  p.  274; 
Virchow's  'Archiv,'  ii.,  p.  84;  '  Correspondenzblatt  fur  Psychiatrie,'  1858,  8; 
'Zeitschrift  fiir  Psychiatrie.'  x.,  1853,  p.  294;  xv.,  pp.  426,  680;  xviii.,  p.  66;  R. 
Fischer,  1854, 1.  c,  p.  8.:  'Wiener  Bericht,'  1858,  pp.  190,  207,  268,  308;  'Archives 
Gener.,'  1859,  Mars;  'Gaz.  d.  Hopit.,'  1860,  22. 

A  consideration  of  the  pathological  changes  which  have  been  described 
shows  that  the  principle  expressed  in  the  statement  made  by  Esquirol 
towards  the  end  of  his  famous  career  (1835),  viz.,  that  pathological  ana- 
tomy has  done  nothing  towards  establishing  the  material  conditions  of 
insanity,_ no  longer  holds  good;  it  may  even  be  admitted  that  from  the 
pathological  anatomical  stand-point  of  that  time  something  definite  could 
be  said  regarding  mental  diseases.  Keeping  in  view  the  great  and  well- 
constituted  results,  negative  as  well  as  positive,  and  altogether  excludino- 
rare  and  more  isolated  observations,  we  shall  attempt,  in  the  folloAving 
paragraph,  to  compare  the  various  states  of  psychical  disease  with  the 
anatomical  conditions  which  most  frequently  correspond  to  them.  With 
this  view,  we  shall  divide  the  various  cases  of  insanity  into  three  classes: 
1st,  Acute  recent  cases  of  melancholia  and  mania;  2cl,  Chronic  cases  of 
protracted,  exhausting  melancholia  and  mania,  partial  dementia  and  de- 
mentia; 3d,  Paralytic  dementia. 


'  See  '  Diagnost.  Bemerkungen,'  etc.,  by  the  Author,  1.  c. 
20 


306  PATHOLOGICAL  ANATOMY  OF  THE  BRAIN. 


I.  Acute  Insanity. 

§  192.  (1.)  As  in  a  considerable  number  of  cases  of  acute  insanity  the 
brain,  on  anatomical  examination,  appears  perfectly  healthy,  it  must,  in 
the  present  state  of  science,  be  assumed  that  the  symptoms  very  often 
depend  upon  simple  nervous  irritation  of  the  brain,  or  upon  disorders  of 
nutrition  which  are  as  yet  unknown. 

(2.)  When  palpable  disorders  exist,  they  consist  chiefly  in  anaemia, 
with  more  or  less  serous  infiltration,  or  (more  frequently)  in  hyperaemia 
of  the  entire  brain,  and  particularly  in  simple  and  ecchymotic  hyperaemia 
of  the  delicate  membranes  and  cortical  gray  substance.  These  hypere- 
mias appear  sometimes  to  produce,  and  at  other  times  merely  to  accom- 
pany, other  morbid  processes  of  nutrition  which  lead  to  further  conse- 
quences. 

(3.)  This  hyperaemia  is  frequently  accompanied  by  thickening  and 
opacity  of  the  membranes,  the  result  of  chronic  stasis.  This_  may,  in 
certain  cases,  proceed  from  the  same  causes  as  the  hyperaemia  itself;  in 
others,  however,  it  may  be  the  result. 

(4.)  There  is  no  constant  distinct  anatomical  distinction  between 
melancholia  and  mania:  the  disorders  in  both  forms  are,  nevertheless,  not 
entirely  identical. 

(5.)  In  melancholia  the  brain  appears  perfectly  healthy  more  fre- 
quently than  in  mania;'  when  an  anatomical  lesion  exists,  it  does  not 
consist  in  hyperaemia  so  frequently  as  in  mania,  but  rather  in  anaemia  with 
greater  consistence  of  the  cerebral  substance,  or  with  more  or  less  serous 
infiltration. 

(6.)  Mania  presents  more  rarely  than  melancholia  no  lesion  or  simple 
hypersemia.  The  hyperaemia  is  more  profound  and  more  intense  (some- 
times attaining  to  an  erysipelatous  hue  of  the  entire  gray  cortex),  and  it 
more  frequently  proceeds  to  inflammation  and  softening,  which  affects 
the  cortical  substance  in  only  certain  layers,  sometimes  the  middle,  some- 
times the  external  layers.  The  rapid  occurrence  of  extended  softening  of 
this  kind  frequently  corresponds  to  a  state  of  profound  dementia  which 
precedes  death.  The  intense  hyperaemias  which  accompany  or  produce 
the  softening  appear  partly  to  determine  the  violent  maniacal  excitement. 
Frequently  also,  when  the  mania  is  of  long  standing,  there  is  found  pig- 
mentation of  the  cortical  gray  substance. 

II.   Clironic  Insanity. 

(1.)  Cases  in  which  no  anatomical  lesion  is  found  are  here  rarely 
observed;  the  same  may  be  said  of  simple  hyperaemias;  opacity  and 
thickening  of  the  membranes  are  common  (much  more  so  than  in  acute 
insanity). 

(2.)  Many  cases  present  lesions  which  are  never  observed  in  the 
former  class:  namely,  atrophy  of  the  brain,  particularly  of  the  convolu- 
tions; chronic  hydrocephalus,  effusions  into  the  subarachnoid  space, 
pigmentation  of  the  cortical  substance,  extended  and  profound  sclerosis 
of  the  brain. 


'  Besides  many  observers  whom  we  have  already  mentioned,.  Bertolini  and 
Bottex  agree  in  this;  likewise  most  of  the  more  recent  observers:  see  Vienna 
Report,  p.  198. 


PATHOLOGICAL    ANATOMY    OF   THE    BRALN.  307 

(3. )  Here,  softening  is  not  so  frequently  met  with  in  the  superficial 
cortical  layer  as  pigmentation,  superficial  induration  and  adhesion  of  the 
pia  mater;  all  in  very  various  degrees. 

(4.)  In  these  states,  but  perhaps  also  in  the  acute  stages,  slight 
superficial  inflammations  of  the  ventricular  walls  must  necessarily  be  of 
frequent  occurrence;  the  granular  condition  of  the  ependyma  and  the 
frequent  adhesions  of  the  ventricular  surfaces  demonstrate  this. 

(5.)  When  the  disease  reaches  the  chronic  stage,  hyperasmia  ceases; 
when  it  does  exist,  it  is  of  the  nature  of  hyperaemia  ex  vacuo;  some- 
times the  more  or  less  atrophied  brain  is  ansemic  and  cedematous.  All 
the  changes  in  the  brain  are  less  indicative  of  active  processes  than  of 
consecutive  states  and  residues  of  former  processes,  and  of  marasmus — 
corresponding  to  the  character  of  the  symptoms  observed  during  life. 

(6. )  Between  partial  dementia  and  dementia  there  is  as  little  differ- 
ence, anatomically,  as  betAvcen  melancholia  and  mania:  still,  generally 
speaking,  considerable  atrophy  of  the  brain  corresponds  to  a  condition 
of  profound  mental  weakness.  (The  reverse,  however,  does  not  hold 
good.) 

III.  Paralytic  Dementia. 

(1.)  Even  here,  cases  are  occasionally  met  with  where  no  palpable 
changes  exist  appreciable  to  the  naked  'eye;  but  these  are  rare  and  of 
slight  significance,  as  we  knoAV  that  in  such  cases  the  microscope  reveals 
important  anatomical  changes. 

(3.)  The  changes  most  frequently  observed  in  general  paralysis  are 
great  oedema  of  the  membranes,  adhesion  of  the  pia  mater  to  the  cerebral 
surface,  grayish-red  softening,  or  coloration;  and  partial,  superficial  in- 
duration of  the  cortical  substance,  with  increase  of  connective  tissue  and 
destruction  of  the  nervous  elements. 

(3.)  Atrophy  of  the  whole  brain,  or  especially  of  the  convolutions,  is 
very  common;  together  with  its  further  consequences,  induration  of  the 
cerebral  substance,  dilatation  of  the  ventricles,  etc.  The  increase  of 
cellular  tissue  and  development  of  true  connective  tissue  occurs  fre- 
quently in  the  white  substance,  either  generally  diffused  or  limited  to 
certain  portions. 

(4.)  Pachymeningitic  processes,  meningeal  apoplexy,  degeneration  of 
the  cerebral  arteries,  are  common. 

(5. )  The  degeneration  of  the  nerve  substance,  and  in  particular  the 
increase  of  connective  tissue  with  destruction  of  the  nervous  elements, 
may  extend  to  the  spinal  cord  (Rokitansky,  Joffe,  Mildner,  Gulliver);  an 
important  circumstance  in  regard  to  the  symptoms  observed  during  life. 

(6.)  The  anatomical  changes  in  general  paralysis  are  more  evident, 
more  characteristic,  and  more  general  than  in  any  other  form  of  insanity: 
still,  they  are  not  always  identical,  but  constantly  present  certain  varie- 
ties. This  appears  to  depend  upon  the  fact,  that  in  some  cases  one  and 
in  other  cases  another  element  of  the  disease  is  the  most  prominent  (it 
may  be  meningitis,  or  atrophy  of  the  entire  brain,  or  sclerosis  of  the 
cortical  substance) ;  and  this  may  depend  upon  the  more  rapid  or  more 
acute  course  of  the  disease. 

From  what  has  been  said,  we  arrive  at  the  following  general  conclu- 
sions:— 

[a.)  Insanity,  whether  acute  or  chronic,  may  be  the  result  of  simple 
abnormal  excitation  or  nutrition  of  the  brain,  without  the  existence  of 
any  palpable  change. 


308  PATHOLOGICAL    ANATOMY    OF    THE    BRAIN. 

{b.)  In  the  majority  of  cases  this  is  not  the  case;  it  depends  upon 
palpable  diseases  which  are  generally  distinct  in  proportion  to  the  dura- 
tion of  the  insanity.  These  consist  partly  in  hyperemia  and  inflamma- 
tory processes,  which,  as  a  rule,  are  first  observed  in  the  pia  mater  and 
cortical  substance,  penetrate  to  various  depths  of  the  cerebral  substance, 
and,  if  not  arrested,  terminate  in  incurable  destruction  and  atrophy  of 
the  cerebral  substance — a  lesion  to  which  the  group  of  symptoms  of  de- 
mentia corresponds. 

(c.)  Frequently,  however,  it  is  non-inflammatory  changes  in  nutrition, 
recognized  only  in  their  final  results — viz.,  marasmus  of  the  brain — which 
correspond  to  the  serious  secondary  forms.  The  initiatory  periods  and 
stages  of  development  of  these  nutrient  changes,  which  correspond  to  the 
primary  forms,  as  yet  are  uninvestigated.  To  these  processes  we  may 
give  the  name  of  atrophic  irritation  of  the  brain. 

(d.)  Our  knowledge  of  symptoms'is  not  yet  so  far  advanced  as  to  en- 
able us  to  state  with  certainty  whether,  in  a  given  case  of  insanity,  ana- 
tomical changes  exist,  and  where  they  are  situated;  but  the  facts  which 
we  observe  enable  us  to  speak  with  as  much  confidence  as  we  can  in  any 
other  diseases  of  the  nervous  system. 

{e. )  The  most  important  circumstance  in  regard  to  anatomical  diag- 
nosis and  to  prognosis  is  the  existence  or  non-existence  of  severe  motory 
disorders,  in  particulai'  of  general  progressive  paralysis. 


PATHOLOGICAL    ANATOMY    OF    OTHKK    ORGANS.  309 


CHAPTER   11. 
THE   PATHOLOGICAL   ANATOMY   OF   OTHER   ORGANS. 

§  193.  In  describing  the  pathological  changes  which  take  place  in 
other  organs,  we  shall  restrict  ourselves  to  those  which  are  practically 
most  important,  or  theoretically  most  interesting — in  the  first  place,  in 
so  far  as  they  are  amongst  the  most  frequent  causes  of  death  in  the 
insane,  and  in  general  possess  great  clinical  interest;  and,  in  the  second 
place,  in  so  far  as  they  occur  with  a  certain  degree  of  regularity  in  those 
cerebral  diseases,  or  even  have  essentially  a  pathological  connection  with 
them.  All  these  changes  are  of  the  utmost  importance  to  the  physician; 
and  numerous  fallacies  have  been  introduced  into  the  theory  of  insanity 
by  the  narrow  views  which  have  been  held  regarding  them.  Thus,  if  in 
an  insane  person  disease  of  the  spleen  or  cirrhosis  of  the  liver  was  discov- 
ered, the  conclusion  was  at  once  arrived  at  that  diseases  of  this  kind  only 
were  to  be  considered  as  physical  conditions  of  insanity;  examples  were 
collected  on  all  sides,  and  a  theory  of  the  psychical  significance  of  the 
viscera  was  framed.  Such  theories,  although  every  day  refuted  by  obser- 
vation, and  at  the  present  time  generally  abandoned,  still  occasionally 
give  rise  to  misconceptions.  It  is  now  beyond  doubt  that  the  insane 
may  die  of  any  disease,  whether  acute  or  chronic,  which  affects  other 
persons;  and  the  following  remarks  may  be  considered  as  supiDlementary 
to  what  has  already  been  said  regarding  etiology. 

Of  general  or  blood  diseases,  those  most  frequently  met  with  in  the 
insane,  especially  in  females,  are  the  anmmic  states  (see  §  106).  In  spite 
of  the  most  careful  nourishment,  profound  anaemia  with  a  waxy  hue  of 
the  entire  skin  and  a  general  puffed-up  appearance  is  sometimes  s>Qep. 
during  the  course  of  the  cerebral  affection  which  lies  at  the  foundation  of 
general  paralysis.  There  (1849)  found  in  these  patients,  even  although 
suffering  from  pneumonia,  a  serous  condition  of  the  blood,  the  clots  being 
without  consistence.  Many  inmates  of  asylums  for  the  insane,  paralytics, 
dements,  etc.,  die  from  anaemia  and  marasmus  without  any  serious  local 
affections,  except,  perhaps,  a  slight  degree  of  atheroma  of  the  arteries 
being  discovered. 

Typhus  fever  is  rarely  met  with  in  the  insane  ;  nevertheless,  it  some- 
times occurs  in  an  epidemic  form,  as,  for  example,  in  the  asylum  at 
Schleswig  (Gaye).'  Sometimes  the  fever  exercises  a  persistent  beneficial 
influence  upon  the  insanity  (in  Schleswig  this  was  observed  four  times  in 
forty-nine  cases,  two  being  of  mania  and  two  of  melancholia). 

Cholera  makes  more  or  less  considerable  ravages  in  asylums.  It  is 
sometimes  very  fatal  amongst  the  old  and  infirm  inhabitants  of  institu- 
tions devoted  to  chronic  cases  (for  example,  Salpetriere).  The  remark- 
able immunity  which  several  asylums  enjoyed  from  epidemics  of  cholera 
(for  example,  Bethlehem  in  1832,  1848,  and  1849)  does  not  at  all  depend 
upon  the  insane  being  less  predisj^osed  to  its  attack.     The  disease  seldom 


Ztschr.  fur  Psychiatrie,'  ix.,  1852,  p.  173. 


310  PATHOLOGICAL    ANATOMY    OF    OTHER    ORGANS. 

exercises  a  beneficial  influence  upon  the  insanity;  it  more  frequently 
exercises  an  unfavorable  effect  both  on  the  bodily  and  mental  condition 
(marasmus). 

Dysentery  is  very  common;  epidemics  of  it  have  been  occasionally 
observed  (for  example,  by  Stoltz).'  The  mortality  is  generally  consider- 
able. In  the  epidemic  just  referred  to,  the  disease  had  no  appreciable 
effect  upon  the  mental  disturbance  ;  even  periodic  attacks  of  mania  were 
neither  interrupted  nor  prevented. 

Regarding  intermittent  fever,  see  p.  132. 

Cancer  appears  to  be  rare  amongst  the  insane.  In  the  Vienna  Asylum,  only 
six  cases  were  met  with  in  384  autopsies. 

§  194.  Amongst  the  local  affections  frequently  met  with  in  insanity, 
we  may  mention,  in  the  first  place,  that  much-discussed  affection  of  the 
external  ear  usually  described  under  the  name  of  haematoma  of  the  ear 
(gethilmatoma,  also  erysipelas  of  the  external  ear).  The  skin  of  the  con- 
cha becomes  swollen,  smooth,  and  tense,  and  indistinct  fluctuation  may 
be  felt ;  the  entire  ear  becomes  painful,  hot,  and  red.  If  cut  into,  there 
is  observed  a  cavity  filled  with  half-clotted,  half-fluid  blood,  which  rap- 
idly fills  again  after  being  emptied.  Sometimes  the  cavity  empties  itself 
by  spontaneous  rupture.  Upon  closer  examination,  the  tumor  is  seen  to 
consist  of  an  extravasation  of  blood  under  the  perichondrium,  which  is 
thereby  separated  from  the  cartilage.  In  a  few  weeks,  the  redness  and 
swelling  usually  abate;  there  remains  more  or  less  thickening  of  the 
affected  part — according  to  some,  owing  to  the  formation  of  new  layers  of 
cartilage — which  is  afterwards  followed  by  shrivelling  and  persistent 
deformity  of  the  concha  auris.  The  mode  of  origin  of  this  disease  is 
still  the  subject  of  discussion,  and  there  already  exists  an  abundant  lite- 
rature on  the  subject — more  so,  indeed,  than  the  question  is  worth. 
While  one  class  of  observers  consider  it  to  be  a  process  of  spontaneous 
origin  more  or  less  connected  with  the  changes  within  the  cranium  (for 
example,  Hoffmann,''  a  hgemorrhagic  inflammation  of  the  cartilage,  anal- 
ogous to  haemorrhagic  pachymeningitis;  others,  as  connected  with  cere- 
bral congestion),  another  class  declares  that  it  is  solely  caused  by  external 
circumstances, — by  injuries,  sometimes  by  knocking  the  head  against  the 
bedposts— at  other  times,  and  particularly,  by  the  pulling  and  tugging 
which  the  ear  undergoes  by  cruel  and  barbarous  attendants.  This  view 
of  a  purely  accidental  and  traumatic  origin,  which  has  been  in  recent 
times  advocated  especially  by  Gudden,'  is  the  most  probable.  The  affec- 
tion is  almost  solely  confined  to  male  patients  (by  male  attendants)  and 
to  asylums.  It  occurs  more  frequently  in  the  left  ear  (suits  the  right 
hand^of  the  attendant);  it  is  rapid  in  its  origin;  the  impression  of  the 
finger-nails  is  sometimes  observed;  and  the  affection  can,  by  care  on  the 
part  of  the  attendants,  be  made  entirely  to  disappear  in  well-regulated 
asylums; 

Ludwig  states  that  he  has  often  observed,  by  means  of  the  ophthalmoscope, 
changes  in  the  eyes  of  the  insane,  and  that  these  diseases  are  sometimes  perma- 
nent, sometimes  transitory— coming  and  going  with  the  paroxysms  (the  latter 
consisting  of  hyperemia  of  the  internal  parts  of  the  eye).  These  facts,  though 
not  sufiSciently  minute,  are  very  interesting,  and  merit  further  investigation. 


1  '  Psych.  Corr.-Bl.,  1857,  No.  3. 

2  Giinsb.,  'Ztschr.,'  vi.,  p.  250. 

3  'Ztschr.  f.  Psych.,'  xvii.,  1860,  2. 


PATHOLOGICAL    ANATOMY    OF    OTHER    ORGANS.  311 

§  195.  Amongst  the  other  organic  alterations  met  with  in  the  insane, 
those  of  tJie  thoracic  organs  are,  on  account  of  their  great  clinical  import- 
ance and  frequently  fatal  termination,  the  most  important. 

I.  Ai7iormalities  of  the  organs  of  res2nration. — The  most  important  of 
these  are  pneumonia,  pulmonary  gangrene,  and  phthisis.  A  large  pro- 
jiortion  of  the  insane  die  of  pneumonia,  especially  those  with  weak  and 
deteriorated  constitutions,  and,  in  particular,  many  general  paralytics. 
Calmeil  found  pneumonia  to  he  the  cause  of  death  in  one-fifth;  Aubanel 
and  Thore,  in  one-seventh.  In  Sachsenberg,  it  was  the  cause  of  death  in 
one-ninth,  and  in  the  Schleswig  Asylum  (Gaye),'  in  one-sixth  of  the  fatal 
cases.  As  in  hospitals  for  old  men,  so  in  asylums  for  the  insane,  there 
occur,  especially  in  the  winter  months,  many  sudden  deaths  from  this 
cause.  These  patients  do  not  show  during  life  the  ordinary  series  of 
symptoms  of  pneumonia.  Rigors  are  seldom  observed;  likewise  cough, 
expectoration,  and  pain.  Dyspnoea,  on  the  contrary,  is  usually  observed 
in  a  greater  or  less  degree.  The  only  symptom  which  renders  our  diag- 
nosis certain  is  naturally  the  presence  of  the  physical  signs.  In  every  case, 
therefore,  where  a  patient  shows  symptoms  of  illness  (loss  of  appetite, 
thirst,  foul  tongue,  and  increased  frequency  of  pulse),  the  thoracic  organs 
ought  to  be  minutely  examined.  The  course  of  pneumonia,  especially  in 
paralytics,  is  generally  rapid,  and  therapeutic  measures  are  quite  as  inef- 
fectual as  in  the  pneumonia  of  aged  persons.  In  an  anatomical  point  of 
view,  these  cases  present  nothing  peculiar.  Loiular  pneumonia  is  very 
frequent,  especially  in  cases  where  the  patients  presented  during  life  the 
symptoms  of  great  exhaustion;  in  paralytics,  it  may  frequently  originate 
through  the  accumulation  of  the  bronchial  secretion  in  the  finer  bronchial 
tubes,  and  through  the  impaction  of  foreign  substances  in  the  air- 
passages  (food,  etc). 

Gangrene  of  the  lungs,  which  has  sometimes  been  observed  suddenly 
to  become  frequent  in  prisons,  has  been  well  known  and  appreciated  in 
the  insane  since  the  days  of  Guislain.^  This  author  observed  gangrene 
of  the  lungs  to  occur  almost  exclusively  in  patients  who  had  refused  their 
food  and  died  of  inanition:  in  such  patients,  however,  it  was  very  fre- 
quent (nine  times  in  thirteen  deaths  of  this  description).  In  these 
patients,  of  whom  several  had  lived  for  from  twenty  to  sixty  days  on 
nothing  but  water,  Guislain  considered  the  impoverishment  of  the  blood 
— a  species  of  scorbutic  state — to  be  the  primary  condition  and  special 
cause  of  the  gangrene:  a  dark-red,  brown-red,  and,  finally,  cyanotic  hue 
of  the  cheeks,  was,  in  his  estimation,  an  important  symptom  during  life. 
It  generally  occurred  in  patients  who  had  manifested  symptoms  of  dimi- 
nution of  the  general  sensibility — indifference  to  cold,  heat,  and  pain; 
who  could  stare  for  a  long  time  at  the  sun,  etc.  Neither  pain,  cough, 
dyspnoea,  nor  fever  existed;  the  pulse  was  generally  slower  than  usual — 
other  observers  (Thore)  found  it  accelerated — and  the  temperature  of  the 
skin  was  very  low.  In  persons  not  insane,  gangrene  of  the  lungs  is  ordi- 
narily accompanied  by  violent  symptoms.  The  gangi'ene  is  sometimes 
limited,  sometimes  diffuse.  In  seven  out  of  nine  of  Guislain's  cases,  it 
was  the  left  lung  which  was  affected:  in  none  of  the  cases  was  there  gas- 
tritis present,  which  certain  authors  say  always  exists  in  certain  individ- 
uals who  refuse  their  food. 

1  'Ztschr.  f.  Psych.,'  x.,  1853,  p.  569. 

'  "Memoiresur  la  Gangrene  des  Poumons  chez  les  Alienes,"  'Gaz.  Medic.,' 
1836,  and  in  the  'Phrenopathies.' 


312  PATHOLOGICAL    ANATOMY    OF    OTHER    ORGANS. 

Since  the  publication  of  Guislain's  work,  gangrene  of  the  kings  has 
been  studied  in  the  insane  by  Ferrus,  Calmeil,  Webster,  Thore,  etc. ;  from 
the  German  asyhims  there  have  recently  issued  many  valuable  works 
(especially  that  of  Fischel)'  and  useful  individual  facts.  In  the  Prague 
Asylum,  in  six  years,  twenty-five  cases  (in  7.4  per  cent  of  the  deaths,  in 
only  1.6  per  cent  of  the  other  autopsies,  in  the  Pathological  Institute) 
were  observed:  of  these,  twelve  were  melancholies;  the  others  suffered 
from  dementia,  epilepsy,  mania.  Refusal  of  food  and  bad  nutriment 
were  the  principal  causes;  on  one  occasion  it  occurred  in  a  patient  who 
had  a  tendency  to  eat  his  faeces.  In  the  Vienna  Asylum,  in  three  years 
(1853  to  1855),  gangrene  of  the  lungs  was  discovered  fifteen  times  in  60:^ 
autopsies,  and  of  these  five  were  consecutive  to  refusal  of  food. 

The  observations  w  3h  have  hitherto  been  made  incontestably  prove 
that  the  disease  is  no  confined  to  those  cases  in  which  food  is  refused 
in  melancholia,  althou^  in  these  it  is  especially  frequent.  That  in  these 
cases  the  abstinence  an  the  inanition  are  actually  the  cause  of  the  mal- 
ady is  shown  by  the  fac  that  it  also  occurs  in  cases  of  stricture  of  the 
oesophagus,  and  that  ii  persons  also  who  are  profoundly  weakened  by 
inanition,  gangrene  is  observed  in  other  parts — in  the  cheeks,  the  genital 
organs,  etc. ;  all  the  circumstances  render  Meyer's  theory,"  that  gangrene 
of  the  lungs  arises  directly  from  the  penetration  of  particles  of  food  into 
the  air-passages  during  the  forced  alimentation  of  individuals  who  refuse 
their  food,  less  probable.  In  certain  cases,  also,  gangrene  of  the  lungs  is 
evidently  the  result  of  general  septic  infection,  originating,  for  example, 
from  a  bedsore. 

In  states  of  inanition,  the  symptoms  (according  to  Fischel)  are  gener- 
ally the  following: — After  a  period  during  which  the  patient  has  become 
rapidly  emaciated,  fever,  cough,  and  accelerated  respiration  set  in;  the 
patient  presents  the  symptoms  of  catarrh,  with  pain  and  oppression  in 
breathing,  great  muscular  weakness,  coldness  of  the  extremities,  pallor  of 
the  skin,  and  deep-red  or  cyanotic  hue  of  the  cheeks.  Soon  the  breath 
and  the  sputa  assume  a  gangrenous  odor;  the  physical  signs  are  those  of 
pneumonic  solidification,  pleuritic  exudation,  of  a  cavity — sometimes  of 
pneumo-thorax  and  haBmoptysis:  extreme  emaciation  and  weakness, 
diarrhoea,  etc.,  set  in,  and  death  from  anemia,  pyasmia,  pneumo-thorax, 
or  profuse  hemorrhage  ensues,  in  from  ten  days  to  three  weeks.  In  pro- 
found melancholia  and  dementia,  the  symptoms  are  sometimes  very 
insignificant. 

Example  L. — Melancholia  after  mental  impressions  ;  refusal  of  food ;  death  ; 
gangrene  of  the  lungs. — During  our  last  political  agitation,  a  lady,  set.  54,  of 
sensitive  disposition,  and  who  had  hitherto  led  a  very  quiet  life,  was  violently 
affected  by  the  sight  of  several  armed  men  fighting  under  her  window.  The 
violent  shock  was  rapidly  followed  by  a  state  of  mental  confusion,  and  several 
days  passed  before  it  was  noticed  that  she  took  no  food.  Three,  five,  nine  days 
were  passed  in  exhortation  by  her  family;  a  thousand  questions  were  asked, 
all  sorts  of  food  were  offered  to  her,  but  nothing  could  overcome  her  aversion  to 
eat.  A  physician  was  called,  and  applied  fifteen  leeches  to  the  epigastrium. 
The  great  falling  ofl:  in  her  appearance,  the  emaciation,  the  melancholia,  which 
constantly  became  more  profound,  awakened  the  anxiety  of  her  family,  and  she 
was  admitted  into  our  asylum  on  the  4th  Febi-uary,  1831.  I  recognized  her 
refusal  of  food  in  the  color  of  her  countenance:  on  putting  some  questions,  I 
learned  that  Madame  B —  had,  for  the  last  four  weeks,  taken  nothing  but  a  few 
basins  of  milk-soup  and  some  weak  beef-tea.  The  face  was  of  a  dark-red  color; 
cheeks,  point  of  the  nose,  and  lobes  of  the  ears  were  brown;   the  pupils  were 

1  Prager  '  Vierteljahrschrift.'  Bd.  xiii.,  1847,  p.  1. 
^ '  Charite-Aimalen,'  v.,  3,  p.  154. 


PATHOLOGICAL  ANATOMY  OF  OTHER  ORGANS.  313 

dilated,  and  the  white  of  tlie  eyes  was  ghstening  and  of  a  bhie  shade;  the  hair, 
which,  according  to  the  testimony  of  her  relatives,  was  usually  smooth,  had  been 
for  some  days  extremely  dry,  and  had  assumed  a  hue  which  could  also  be 
recognized  in  the  iris. 

It  was  only  with  gi-eat  trouble  that  she  could  be  persuaded  to  take  a  few 
spoonfuls  of  beef-tea;  the  patient,  who  was  very  strong,  struggled  violently  with 
the  attendants,  so  that  the  melancholia  actually  passed  into  mania.  The  emaci- 
ation made  fearful  progress;  the  countenance  became  brown,  the  lips  somewhat 
livid;  and  soon  the  hands  and  feet,  especially  at  the  phalanges,  became  iierfectly 
cyanotic.  The  patient  always  strenuously  resisted  being  fed;  she  became  motien- 
less,  and  soon  an  ecstatic  condition  was  added  to  the  symptoms  of  melancholia. 
It  was  with  difficulty  that  she  could  from  time  to  time  be  forced  to  take  a  cup  of 
milk  or  soup;  and  in  order  to  overcome  her  resistance,  we  had  recourse  to  the 
swing  chair,  but  without  success. 

Her  breath  had  an  insupportable  odor;  the  sputa  were  brown,  streaked  with 
bright  red;  in  a  few  days  the  expectoration  became  cojiious,  not  actually  puru- 
lent, but  sanious.  The  countenance  had  so  fallen,  that  the  patient  seemed  to  be 
of  great  age.  She  gradually  became  weaker;  occasionally  she  took  a  little  food, 
and  during  the  last  few  days  took  anything  that  was  offered  her. 

On  examination  of  the  body,  the  brain  and  its  membranes  appeared  normal. 
The  contents  of  the  abdomen  presented  no  trace  of  inflammation,  the  stomach 
was  not  injected  nor  at  all  drawn  together.  The  gall-bladder  was  full  of  very 
black  bile,  and  the  spleen  and  mesenteric  vessels  contained  blood  so  very  dark  in 
color  as  to  confirm  me  in  what  has  been  said  regarding  this  condition  by  the  cel- 
ebrated Haller. 

As  I,  after  opening  the  thorax,  was  lifting  up  the  left  lung,  my  finger  pene- 
trated its  substance;  and  such  an  insupportable  odor  arose  from  the  rent,  that  I 
was  obliged  to  stop  my  investigation  for  a  little.  The  posterior  aspect  of  the 
superior  lobe  of  the  extracted  lung  was  of  a  black  color,  interspei'sed  with  green 
and  brown  spots.  An  incision  made  into  this  part  showed  that  the  tissue  was 
very  easily  torn,  A  bloody,  black,  stinking  liquid,  like  the  fluid  in  a  gangreous 
limb,  permeated  the  pulmonary  tissue;  here  and  there  a  few  purulent  particles 
were  seen.  On  scraping  with  the  scapel,  the  blade  became  covered  with  a  brown, 
Aiscous,  putrid  mass;  bright-red  stripes  penetrated  the  tissue  in  all  directions; 
internally,  the  decomposition  extended  similarly  into  the  lung.  The  entire 
gangrenous  portion  was  about  the  size  of  a  flattened  ball,  five  inches  in  diameter. 
The  bronchi  were  filled  with  a  red,  frothy,  foetid  fluid;  the  right  lun^  was 
healthy.  (Guislain,  "  Memoire  sur  la  Gangrene  des  Poumons  ches  les  AUenes," 
'  Gazette  Medicale,'  1836,  p.  341.) 

The  frequency  of  phthsis  pulmonalis  in  the  insane  has  been 
acknowledged  by  observers  from  the  days  of  Lorry  to  the  present  time. 
We  have,  however,  no  definite  statistical  proof  that  this  disease  is 
actually  more  frequent  amongst  the  insane  in  asylums  than  among 
persons  living  under  similar  conditions  (in  institutions,  etc.). 

Esquirol  considered  that  more  than  a  third  of  his  melancholies  were 
phthisical;  Calmeil  found  tuberculosis  in  fths,  Webster _  in  |th,  Sc. 
Pinel  in  |-th  of  their  autopsies;  in  Vienna  it  was  met  Avith  in  more  than 
|d  (in  a  total  of  602  autopsies  made  in  the  three  years  1853  to  1855) ;  in 
Prague,  in  1843  and  1843,  in  more  than  fths  (Fischel);  in  Eberbach,  in 
-^th;  in  the  asylum  for  chronic  cases  at  Colditz,  in  y^^ths  (Voppel);  in 
Palermo,  in  thirteen  years,  in  192  cases  of  death,  in  almost  f  (Pignocco); 
in  Han  well,  in  four  years,  amongst  the  female  patients,  in  not  quite  -^th; 
in  Bethlehem,  in  six  years,  1842-1848,  in  |th;  in  certain  asylums — ^for 
example,  in  Bicetre — its  rarity  is  remarkable  (Thore,  1.  c).  The  gen- 
eral statistics  made  by  Hagen'  for  a  great  many  asylums  sliow  that  in 
asylums  generally  a  little  more  than  one-fourth  of  the  deaths  are  due  to 
phthisis,  and  that  this  proportion  is  almost  the  same  as  for  the  general 
population  above  fourteen  years  of  age.  This  may  be  true  in  regard  to 
large  towns,  and  in  particuhir  to  Vienna  and  Prague;  but  for  tlie  rural 

'  '  Ztschr.  f.  Psychiatrie,'  vii.,  1850,  p.  257. 


314  PATHOLOGICAL    ANATOMY    OF    OTHER   ORGANS. 

population  this  estimate  is  for  most  localities  far  too  high,  so  that  we 
must  still  assume  that  phthisis  is  more  frequent  amongstthose  who  in- 
habit large  institutions  (not  asylums  merely)  than  amongst  the  general 
population.  It  is  not  merely  on  account  of  its  mortality  that  phthisis  is 
important  in  insanity;  it  is  certainly  also  of  great  pathogenetic  value, 
owing  to  which  it  may  stand  in  various  relations  to  the  insanity. 

Tuberculosis  is  developed  principally  in  the  primary  forms,  and  its 
course  sometimes  presents  many  deviations  from  the  ordinary  symptoms; 
in  particular,  there  is  occasionally  observed  a  striking  interchange  in  the 
intensity  of  the  symptoms  of  the  pulmonary  and  of  the  cerebral  affection, 
so  that  apparent  improvement  of  the  one  always  coincides  with  aggi-ava- 
tion  of  the  other.  Still,  this  interchange  is  not  only  very  inconstant, 
but  it  is  also  merely  apparent;  the  subjective  symptoms  of  the  pulmonary 
affection  disappear  in  profound  mental  disorder,  while  the  objective, 
physical  signs  show  that  the  process  continues  its  ravages.  Frequent 
examination  of  the  patient  is  therefore  necessary. 

The  statement  that  the  delirium  of  the  phthisical  insane  has  a  certain 
specific  character  is  equally  incorrect  (see  §  106). 

All  the  various  diseases  of  the  respiratory  organs  are  met  with  in 
insanity.  After  long-continued  violent  screaming  and  excitement,  acute 
catarrh  of  the  larynx  and  osdema  of  the  glottis  may  ensue.  Pleurisy  has 
been  observed  by  Sc.  Pinel  7  times  in  135,  by  Thore  8  times  in  76,  in 
the  Vienna  Asylum  89  times  in  431  autopsies;  pulmonary  apoplexy  was 
observed  by  Jessen'  on  6  occasions,  etc.  Hypostatic  hyperjBmia  of  the 
lungs  is  also  frequent  in  those  who  have  lain  for  a  long  time  in  the  same 
position,  etc.  These  various  affections  present  nothing  peculiar  in  the 
insane;  they  are  worthy  of  mention  principally  on  account  of  the  atten- 
tion which  their  diagnosis  demands  during  life. 

II.  Affections  of  the  heart.  Nasse,''  from  statistics  gathered  from  the 
older  works  on  the  subject,  concluded  that  heart-diseases  were  frequent 
and  of  great  importance  in  the  insane.  Subsequent  observers  differ 
much  in  their  opinions  regarding  their  frequency  (Esquirol  met  with 
affections  of  the  heart  in  only  one-fifteenth  of  his  melancholies,  Webster 
in  one-eighth,  Bayle  in  one-sixth,  Calmeil  and  Thore' in  almost  one-third). 
The  newest  and  most  reliable  statistics  show  only  a  very  average  fre- 
quency. In  the  Vienna  Asylum,  in  602  autopsies,  affections  of  the 
heart  were  met  with  in  about  one-eighth;^  still,  a  large  proportion  of 
these  belong  to  the  class  which  is  of  more  importance  in  regard  to  the 
completeness  of  the  report  than  in  a  clinical  sense.  Bazin^  (in  Bordeaux) 
found  only  three  cases  of  organic  heart-disease  in  343  post-mortem 
examinations  of  insane  women.  According  to  these  figures,  we  may 
assume  that  the  ordinary  affections  of  the  heart  are  rather  rare  than  fre- 
quent in  the  insane.  Dilatation  and  incrustation  of  the  aorta  occur 
more  frequently  (for  example,  in  about  one-sixth  of  the  602  cases 
examined  in  the  Vienna  Asylum),  which  is  naturally,  in  many  cases, 

'  Jacobi  and  Nasse,  'Ztschr.,'  i.,  p.  677. 

2  'Zeitschr.  f.  Psych.  Aerzte,'  1818,  i.,  1. 

^  See  the  writings  of  Esquirol  and  the  f  orementioned  work  of  Thore. 

■*  '  Vienna  Report, '  p.  204.  Certain  recent  alterations  originating  shortly  before 
death  are  not  included:  I  also  thought  it  necessary  to  exclude  fourteen  cases  of 
mere  thickening  of  the  valves.  Amongst  the  cases  of  insufficiency,  there  are  many 
very  slight  changes  in  the  aortic  valves,  and  many  cases  of  simple  hypertrophy. 

^  '  Ann.  Med.  Psych.,'  vi.,  1854,  p.  659.  For  the  frequency  of  heart-disease  in 
the  reports  of  Voppel,  see  the  above,  p.  200. 


PATHOLOGICAL    ANATOMY    OF    OTHER    ORGANS.  315 

connected  with  other  affections  of  the  heart  and  with  sclerosis  of  the 
cerebral  arteries. 

§  196.  Ahnormalities  in  the  abdominal  organs. — Amongst  the  acute 
organic  diseases  to  which  the  insane  snccumb,  acute  intestinal  catarrh 
occupies  a  prominent  position.  It  appears  in  the  ordinary  manner,  as 
injection  with  secretion  of  mucus,  etc.,  or  with  follicular  ulceration,  or 
us  an  exudative  process  with  relaxation,  maceration,  and  extensive 
softening  of  the  mucous  membrane,  which  may  be  stripped  off  in  the 
form  of  a  pulpy  bloody  substance  (especially  in  the  ileum).  These 
catarrhs  are  the  fundamental  cause  of  the  colliquative  diarrhoeas  whose 
appearance  in  exhausted  and  weak  individuals  is  very  properly  considered 
as  ominous;  the  maceration  in  the  ileum  may  exist  without  diarrhoeL 
Many  general  paralytics,  and  not  a  few  melancholies  and  maniacs,  are 
carried  off  by  these  diseases.  Their  causes  are  obscure;  in  many  asylums 
the  immoderate  use  of  purgatives  may  contribute  to  their  frequency. 
Their  diagnosis  is  difficult;  loss  of  appetite,  meteorism,  rapid  failing  of 
the  strengtli,  and  diarrhcea  are  always  the  most  constant  symptoms.  The 
frequency  of  their  occurrence  renders  careful  examination  of  the  stools 
necessary  in  all  cases  of  suspicion. 

The  older  observers  attached  much  importance  to  a  narroivmg  of  the 
large  intestine,  which  they  considered  to  be  very  frequent:  these  cases, 
however,  presented  nothing  morbid,  but  merely  a  drawing  together  of 
the  large  intestine — a  condition  frequently  met  with  in  every  pathologi- 
cal theatre.  Occasionally  there  may  be  a  certain  degree  of  contraction 
of  the  intestine  in  consequence  of  prolonged  catarrh. 

Displacement  of  the  colon,  which  Esquirol,  and  afterwards  Bergmann 
and  others,  considered  to  be  an  important  and  frequent  anomaly,  is  like- 
wise altogether  immaterial.  Most  frequently  it  is  caused  by  the  trans- 
verse colon  in  its  middle  portion  or  in  its*  left  half  descending  into  the 
hypogastric  region,  behind  the  symphysis,  or  even  into  the  pelvis,  and 
then  rising  perpendicularly  towards  the  spleen. 

There  are  several  other  disorders  of  the  abdominal  organs  which  may 
be  mentioned,  such. as  hypertrophy  of  the  ganglionic  nerves,  which  has 
been  observed  in  certain  cases;  Rokitansky  (ii.,  p.  871)  observed  "con- 
siderable increase  in  volume  of  the  central  abdominal  ganglia  in  a  case  of 
eminent  hypochondriasis,  together  with  general  tabes;"  anomalies  of  the 
intestines;  prolapsus  of  the  rectum,  which  Bergmann  has  often  seen  in 
dements  affected  with  constipation;  cancer  of  the  stomach  (rare— Esquirol 
observed  a  case  of  it  in  a  woman  who  believed  that  she  had  a  beast  in  her 
stomach);  old  peritoneal  adhesions,  folds  and  adhesions  of  the  bowel,  in 
which  cases  the  flatulence  and  other  obscure  painful  sensations  may  give 
rise  to  peculiar  dehrious  ideas  (a  patient  of  Esquirol's  declared  that  Pon- 
tius Pilate,  all  the  persons  mentioned  in  the  Bible,  and  a  council  of 
popes,  Avere  in  his  belly;  another,  that  there  were  several  devils  there); 
foreign  bodies  in  the  intestinal  canal,  such  as  cherry-stones,  which  m 
some  cases  are  swallowed  in  large  quantities — an  entire  spoon  that  has 
been  swallowed,  etc.;  organic  diseases  of  the  liver;  intestinal  entozoa 
(sometimes  these  are  found  in  unusual  localities);'  diseases  of  the  mesen- 

1  Hayner  (Nasse,  '  Zeitschr.  f .  Psych.  Aerzte,  1818,  Heft  4)  narrates  the  case 
of  a  patient  who  believed  that  he  was  going  to  die  of  starvation,  and  constantly 
complained  of  something  living  in  his  stomach,  and  which  rose  to  his  throat. 
After  death,  seven  lumbrical  worms  were  found  in  the  gall-ducts  of  the  liver,  one 
sticking  half  in  the  ductus  choledochus  and  half  in  the  duodenum,  and  from 
thirty  to  thirty-six  in  the  duodenum  itself.  In  another  case  of  sudden  mania,  a 
lumbrical  worm  was  found  in  the  ductus  choledochus,  and  several  others  in  the 
duodenum. 


316  PATHOLOGICAL    ANATOMY    OF    OTHER   ORGANS. 

teric  glands  (Boiiet  found  in  an  insane  man  who  believed  that  he  had  three 
frogs  in  his  belly,  three  "  scirrhous"  glands  in  the  exact  spot  where  the 
sensation  was  felt).  Bright's  disease  is  exceedingly  rare  amongst  the  in- 
sane as  a  primary  affection,  but  the  slighter  forms  which  accompany  the 
various  marasmatic  states  are  naturally  common.'  Finally,  the  diseases 
of  the  male  and  female  genital  organs  (prolapsus,  hypertrophies,  malig- 
nant polypoid  degenerations,  etc.)  may  be  mentioned  as  important  ano- 
malies. The  latter  (fibroid  tumors  of  the  uterus,  infarctus,  ovarian  cysts, 
etc.)  rarely  give  to  the  delirium  the  character  of  sexual  excitement;  they 
rather  occasion  a  hysterical  disposition  which  may  be  important  in  regard 
to  the  origin  of  the  entire  mental  disturbance.  The  older  as  well  as  the 
rilore  recent  psychological  literature  abounds  in  cases  of  this  description,* 
although  they  are  not  always  related  with  the  necessary  minuteness  and 
pathological  accuracy:  besides  their  theoretical  interest,  they,  above  all, 
show  the  necessity  of  a  minute  examination  of  all  the  organs  accessible  to 
our  means  of  diagnosis. 

^  Fischel,  in  Prague,  had  only  3  cases  of  Bright's  disease  amongst  2,40C 
patients;  the  Vienna  Report  gives  23  cases  to  602  autopsies,  of  which,  however, 
several  were  of  phthisical  persons. 

-  See,  for  example,  the  work  of  Burzorini,  '  On  the  Physical  Conditions  of  In- 
sanity,' Ulm,  1824. 


PBOGKOslS. 


317 


BOOK   FIFTH. 

THE  PROGNOSIS  AND  TEEATMENT   OF  :yiENTAL  DISEASE. 


CHAPTER  I. 
PROGNOSIS. 


§  197.  The  prognosis  in  mental  disease  involves  two  separate  ques- 
tions. In  the  first  place,  Does  the  existing  disease  endanger  life  9  and  in 
the  second  place,  If  life  he  continued,  lohether,  and  to  what  extent,  may 
recovery  from  the  mental  derangement  he  hoped  for? 

The  reply  to  the  first  of  these  questions  often  depends  more  upon  the 
presence  of  serious  disease  in  other  parts,  as  tuberculosis,  heart-disease, 
etc.  (which  are  to  be  estimated  according  to  established  principles)  than 
upon  the  presence  of  the  cerebral  affection .  Amongst  the  purely  cerebral 
affections,  the  most  rapidly  fatal  are  those  serious  degenerations  of  the 
brain  with  the  symptoms  of  general  paralysis  (see  above),  because  they, 
as  a  rule,  prove  fatal  in  from  one  to  three  years,  and  very  often  in  even  a 
much  shorter  period.  Of  unfavorable  prognosis  are  likewise  extensive 
and  intense  hypersemias  of  the  brain,  which  occasionally,  at  a  certain 
stage,  lay  the  foundation  of  mania,  but  more  frequently  come  on  parox- 
ysmally  during  the  course  of  that  disease;  they  may  rapidly  advance  to 
acute  softening  of  the  cortical  substance,  or  may  prove  almost  immedi- 
ately fatal  by  causing  serous  effusions,  extravasations  of  blood,  etc. 
CBdema  of  the  brain,  especially  if  it  comes  on  acutely,  might  be  a  cause 
of  death,  and  the  refusal  of  food  seen  in  certain  forms  of  melancholia,  if 
long  continued,  become  one  of  the  events  dangerous  to  life.  As  a  rule, 
there  is  a  much  greater  tendency  to  death  within  the  earlier  periods, 
during  the  acute  stages  of  melancholia  and  mania,  than  in  those  condi- 
tions of  chronic  irritation  or  more  gradual,  but  incurable,  changes  of 
structure  in  the  brain  which  give  rise  to  chronic  forms,  to  monomania, 
to  melancholia  with  the  character  of  mental  weakness,  or  to  imbecility. 
These  thoroughly  chronic  forms  allow  of  not  only  a  long  duration  of  life, 
but  very  frequently  there  is  noticed  at  an  early  stage  of  the  disease  a  re- 
markable improvement  in  the  state  of  health  of  the  patients,  who  gain 
flesh  and  weight.  Every  asylum  contains  amongst  its  old  inmates  many 
such  examples. 

A  comparison  of  the  death-rate  in  asylums  for  the  insane,  to  be  of  any 
value,  requires  a  minute  inquiry  into  the  various  causes  of  their  differ- 
ence. 

The  mortality  is  always  greater  in  those  establishments  destined  spe- 
cially for  recent  cases  than  in  asylums  proper;  for  the  majority  of  deaths 
amongst  the  insane  occur  within  the  first  twelve  to  eighteen  months  of 
the  malady.  This  is  explained  by  the  fact  that  the  recent  and  acute 
cerebral  affection  may  be  merely  a  complication  of  serious  physical  dis- 


318  PROGNOSIS, 

ease,  and  by  the  frequent  occurrence  of  mania  or  of  general  paralysis  in 
the  early  stages.  The  comparative  frequency  of  this  latter  complication 
tends  more  than  any  other  circumstance  to  modify  the  statistics  in  dif- 
ferent countries  and  in  various  institutions.  It  is  this  also  which  causes 
in  general  a  greater  (earlier)  mortality  amongst  males  than  females.  In 
Bethlehem,  where  no  case  of  more  than  a  year's  standing  and  no 
epileptic  or  paralytic  is  admitted,  and  where  no  case  is  detained  longer 
than  a  year,  the  mortality  was  6-9  per  cent;  St.  Yon,  a  general  asy- 
lum, over  7  per  cent;  Winnenthal,  almost  solely  devoted  to  curable 
cases,  in  the  twenty  years  from  1834  to  1854,  11-13  per  cent; 
Siegburg,  in  the  foiir  years  from  1846  to  1850,  10-11  per  cent;  Sachsen- 
burg,  in  the  ten  years  from  1840  to  1849,  16-17  per  cent;  Han  well,  12 
per  cent;  Lenbus  (for  curable  cases),  in  twenty-four  years,  16  per  cent 
(Mortini);  the  English  poorhouses,  27  per  cent;  the  Antiquaille,  in 
Lyons,  30  per  cent.  It  would  be  not  only  irksome,  but  impracticable,  to 
consider  here  the  various  circumstances  which  cause  the  remarkable  dif- 
ferences presented  by  these  superficial  quotations.  Hitchman  (1850) 
came  to  the  conclusion  (from  the  statistics  of  Hanwell)  that  the  normal 
ratio  of  mortality  is  trij)led  in  mental  disease. 

§  198.  The  decision  on  the  second  question  m  our  prognosis,  viz., 
the  curability  of  the  insanity  when  life  is  not  endatigej'ed,  is  to  be  deter- 
mined by  the  consideration  of  a  great  number  of  special  circumstances, 
and  requires  a  much  more  intimate  knowledge  of  mental  disease.  Here, 
also,  the  statistics  of  the  various  institutions  for  the  insane  afford  us 
much  valuable  information,  inasmuch  as  they  exhibit  a  series  of  the 
results  of  experience,  and  agi'eeing  with  each  other  in  their  various  par- 
ticulars (for  example,  the  incurability  of  secondary  dementia,  the  influ- 
ence of  the  duration  of  the  disease  upon  the  prognosis,  etc.).  It  must, 
however,  be  borne  in  mind  that  many  statistics  regarding  curability  are 
not  to  be  implicitly  trusted;  the  word  cured  not  being  universally  em- 
ployed in  precisely  the  same  sense,  and  no  statistics  can  bring  to  view  all 
the  complicated  circumstances  which  in  concrete  cases  determine  the 
decision  as  to  the  curability  of  the  malady. 

A  primary  consideration,  and  indeed  the  most  important  as  regards 
the  question  of  curability,  is  the  /brw  of  the  insanity  and  the  period  of 
the  disease.  Thus  we  consider  as  quite  incurable  every  form  of  secondary 
dementia  (with  which,  however,  we  must  not  confound  melancholia  with 
stupor,  nor  the  temporary  profound  suspension  of  the  faculties  frequently 
observed  after  mania).  Chronic  mania  is  scarcely  more  susceptible  of 
radical  cure;  occasionally,  however,  it  admits  of  considerable  improve- 
ment, because  the  falseness  or  errors  of  judgment  may  extend  over  a 
large  circle  of  ideas,  or  may,  on  the  contrary,  be  confined  to  a  few  hallu- 
cinations. In  the  last  case,  also,  the  fixity  of  the  ideas  depends  upon  total 
perversion  of  the  psychical  individuality,  which  renders  it  impossible  for 
the  patient  to  throw  off  the  idea  that  continually  follows  him,  to  distin- 
guish his  former  self  mid  the  confusion  of  his  whole  manner  of  contem- 
plation; in  a  word,  to  become  himself  again.  Any  real  improvement, 
therefore  (which  can  only  be  shown  in  the  concealing  of  his  delusions,  in 
his  becoming  accustomed  to  orderly  habits  and  deportment,  and  to  a,  at 
all  events,  mechanical  sense  of  duty),  can  only  be  obtained  after  long- 
continued,  and  in  many  cases  most  energetic  treatment.  Even  then, 
however,  the  result  is  very  uncertain. 

Amongst  the  primary  forms  of  melancholia  and  mania,  my  observa- 
tions (which  correspond  exactly  with  those  of  Flemming)  go  to  prove 


PROGNOSIS.  319 

that  it  is  the  former  in  its  really  primary  stage  which  is  the  more  easy  of 
cure.  If,  on  the  other  hand,  many  other  medical  psychologists  (Jessen, 
Ideler,  Falret,  Ferrus,  Haslam,  Rush,  etc.)  dechire  that  mania,  especially 
manie  agitee,  is,  generally  speaking,  the  most  curable  form  of  insanity, 
it  may  be  that  they  come  to  that  conclusion  from  the  results  of  practice 
in  asylums,  into  which  simple  cases  of  melancholy  seldom  find  their  way, 
but  more  frequently  difficult  cases  and  those  of  long  standing,  and  which 
therefore,  of  course,  come  after  mania  m  the  order  of  curability.  For, 
Yery  naturally,  in  even  tlie  slighter  cases  of  mania,  the  aid  of  the  asylum 
is  souglit,  owing  to  the  condition  of  exaltation;  while  many  cases  of 
moderate  melancholia  are,  when  taken  in  time,  successfully  treated  at 
home.  As  for  chronic  and  protracted  cases  of  melancholia  and  mania, 
however,  it  is  difficult  to  distinguish  any  difference  in  the  prognosis; 
indeed,  more  frequently  a  rapid  interchange  of  both  takes  place,  forming 
a  continual  vacillation  between  exaltation  and  depression. 

Amongst  the  primary  forms,  a  short  stage  of  melancholia  is  more 
favorable  than  a  long  one;  a  state  of  vague,  objectless  emotion,  be  it  sad 
or  cheerful,  and  vague  general  delirium,  is  always  more  favorable  than  the 
appearance  and  continuance  of  fixed  ideas.  It  is  on  this  account  that 
monomanie  exaltee  is  far  less  susceptible  of  cure  than  manie  agitee.  In 
melancholia,  too,  the  appearauce  of  hallucinations  is  decidedly  unfavor- 
able; those  especially  which  refer  the  malady  to  external  agencies  (to 
other  persons,  to  witchcraft,  etc.)  are  remarkably  persistent,  and  intro- 
duce at  a  later  period  a  condition  of  dementia;  when,  on  the  other  hand, 
the  patient  attributes  the  cause  of  his  condition  to  something  within 
himself  (for  example,  to  imaginary  vomiting),  he  is  much  sooner  disposed 
to  quit  his  delusions  (Zeller). 

In  thus  forming  a  prognosis  upon  the  form  of  the  disease,  the  most 
important  consideration  is  always  the  determining  whether  the  mental  dis- 
ease is  still  active  and  in  progress,  or  whether  it  is  only  the  remains  of  an 
exhausted  and  extinct  pathological  process.  Seeing  that  mania  represents 
the  acme  of  all  stages  and  of  all  forms,  it  may  be  given  as  a  practical  rule, 
that  if  a  period  of  mania  be  succeeded  by  a  complete  and  prolonged  calm, 
but  without  really  favorable  indications,  the  patient  is  in  the  greatest 
danger  of  incurability.  The  prognosis,  moreover,  is  especially  difficult 
at  that  stage  when  the  primary  forms  degenerate  into  chronic  mania  and 
mental  weakness,  whicli  degeneration  often  takes  place  after  years  of 
alternating  amelioration  and  relapse.  On  the  one  hand,  the  cessation  of 
all  disturbances  of  the  physical  state,  especially  with  increasing  embon- 
point,  and  on  the  other,  all  permanent  anomalies  of  motion  and  of  sensa- 
tion (convulsions,  changes  in  the  state  of  the  pupils;  loss  of  smell,  of 
taste;  eating  of  faeces,  fixing  the  eyes  upon  tlie  sun,  obstinate  wandering 
muscular  pains,  etc.)  are  to  be  viewed  as  decidedly  unfavorable  symptoms, 
and  such  signs  as  the  following:  the  absence  of  a  return  to  normal  tastes, 
to  healthy  inclination  for  employment — the  constant  leaning  towards  un- 
bounded whimsical  exaggeration,  unaccompanied  by  exaltation  of  the 
sentiments — increased  incoherence  of  ideas,  stupidity  of  countenance, 
etc.,  indicate,  from  the  psychical  side,  continuance  or  further  progress 
of  the  disease. 

§  199.  The  duration  of  the  disease  is,  as  all  experience  has  shown,  of 
greater  importance  as  regards  the  prognosis  in  this  than  in  any  other 
malady.  In  reference  to  this  point,  various  statistics  may  present  slightly 
different  results,  but  the  principle  admits  of  no  exception.  Thus,  in 
Winnenthal,  the  number  discharged  recovered,  of  those  admitted  within 


320  PROGNOSIS. 

the  first  six  months  of  the  disease,  amoiinted  to  G8  per  cent;  after  two 
years'  illness,  18  per  cent;  and,  after  a  duration  of  four  and  a  half  years, 
only  11  per  cent:  in  the  Retreat,  of  admissions  within  the  first  three 
months,  80  per  cent;  from  three  to  twelve  months,  46  per  cent.  Jessen's 
recoveries  in  recent  cases  {i.  e.,  those  of  not  more  than  a  year's  standing 
before  admission)  amounted  to  66  per  cent;  in  cases  of  longer  standing, 
12  per  cent:  in  Leubus,  of  admissions  within  the  first  half  year,  64.16 
per  cent;  within  the  first  year,  34.26  per  cent;  after  a  year's  illness,  20 
per  cent.  In  cases  which  come  under  proper  treatment  within  the  earlier 
months  of  the  disease,  the  proportion  of  recoveries  may  be  estimated  at 
70  per  cent  (Elliuger);  and  Esquirol  estimates  that  after  three  years' 
duration  of  the  disease  only  one  in  thirty  of  the  cases  recover.  The 
liope,  therefore,  of  complete  recovery  becomes  dim,  if  no  appreciable 
step  towards  improvement  takes  place  within  a  year.  Examples,  how- 
ever, are  not  unfrequent  of  recoveries  after  six,  ten,  or  even  twenty 
years'  illness,  as  may  be  occasionally  observed  in  institutions  devoted 
esjoecially  to  chronic  cases.  This  occurs  more  frequently  amongst  females, 
in  whom  a  favorable  influence  is  sometimes  exerted  at  the  climacteric 
period. 

Regarding  the  prognostic  signs  to  be  drawn  from  the  course  of  the 
disease  and  the  manner  in  which  the  symptoms  are  grouped,  periodic 
attacks,  with  the  lucid  intervals  longer  in  duration  than  the  i)aroxysms, 
are  decidedly  unfavorable.     It  generally  happens,  that  with  patients  who 
fall  into  insanity,  and  at  the  earlier  period  of  the  disease  have  an  attack 
once  a  year,  or  once  in  three  years,  or  even  once  in  seven  years,  the 
attacks,  as  time  advances,  become  longer  and  more  serious,  the  lucid 
intervals  shorter,  and  with  each  new  attack  the  prognosis  becomes  more 
unfavorable.     In  continued  cases,  a  gradual  slow  development  of  the  dis- 
ease generally  (but  not  always)  denotes  that  it  will  be  slow  in  its  course 
and  diiScult  of  cure;  while  a  sudden  commencement  is,  as  a  rule,  more 
favorable.     On  the  other  hand,  however,  recoveries  which  take  place 
gradually  and  slowly  are  generally  more  permanent  than  the  rapid  cures, 
which  are  seldom  lasting,  especially  if  the  malady  has  been  of  long  stand- 
ing.    Irregular  alternations  and  violent  displays  are  always  more  favor- 
able than  a  prolonged  continuance  of  the  same  symptoms:  for  instance, 
a  constant  state  of  maniacal  excitement,  a  permanent  and,  at  the  same 
time,  modenite  gaiefS,  constant  voraciousness,  prolonged  refusal  of  food, 
etc.     Xymphomania,  with  its  various  modifications,  is,  in  young  persons, 
of  rather  favorable  prognosis;  but  when  it  appears  later  in  life,  at  the 
climacteric  period,  it  rarely  admits  of  cure.     The  various   conditions 
arising  from  sexual  super-excitation  in  men  of  advanced  years  are  equally 
grave  in  a  prognostic  point  of  view;  they  generally  proceed  to  dementia. 
The  return  of  a  period  of  depression  in  mania  (as,  for  example,  much 
weeping)  is  a  favorable  symptom,  inasmuch  as  a  period  of  melancholy 
frequently  precedes  recovery,  or,  at  least,  sadnes  of  humor  is  followed  by 
a  lucid  interval:  so,  also,  in  every  case  the  return  of  proper  sentiments, 
of  former  desires  and  favorable  pursuits  (work,  music,  etc.),  of  memory, 
of  desire  to  see  relatives,  etc.,  are  to  be  regarded  in  a  favorable  light. 
Numerous  hallucinations  coexistent  with  a  state  of  calm  are  unfavorable. 
A  perfect  state  of  physical  health  (regarding  which  we  can  only  speak  after 
a  minute  and  thorough  examination  of  all  tlie  organs)  in  long-standing 
mental  derangement  is,  and  very  properly  too,  regarded  as  an  inauspi- 
cious circumstance.     On  the  other  hand,  the  return  of  former  bodily 
ailments,  which  had  disappeared  during  the  disease  (as  toothache,  head- 


PKOGNOS18.  321 

ache,  oedema,  hgemorrliage,  etc.),  is  occasionally,  though  by  no  means 
frequently,  observed  to  coexist  with  decided  improvement  in  the  mental 
state — sometimes,  indeed,  with  rapid  recovery.  All  remissions,  and  all 
intermissions  and  lucid  intervals,  becoming  gradually  longer  in  duration, 
are  naturally  favorable.  But  the  best  prognostic  sign  of  all,  is  a  knowl- 
edge on  the  part  of  the  patient  of  the  internal  trouble — the  feeling  of 
illness,  and  a  reaction  of  the  former  self  against  the  state  now  recognized 
as  a  morbid  one:  nevertheless,  as  Jacobi  justly  observes,  ''  the  power  may 
fail  to  carry  through  this  reaction,  and  the  temporary  glimmer  of  self- 
consciousness  be  again  extinguished." 

§  200.  The  causes,  exciting  or  predisposing,  of  the  mental  disease 
have  also  a  prognostic  value.  It  cannot  be  disputed  that  insanity  at  an 
early  age  is  more  frequently  cured  than  when  it  occurs  in  advanced  years. 
Still,  cases  of  recent  insanity  occurring  in  individuals  of  fifty  or  sixty  years 
of  age  frequently  turn  out  favorably,  and  senile  imbecility  is  the  only 
malady  which  presents  absolutely  no  hope  of  recovery.  The  generally 
admitted  fact,  that  insanity  is  more  easy  of  cure  when  it  occurs  in  women, 
is  doubtless  chiefly  owing  to  the  less  frequent  occurrence  in  them  of  gene- 
ral paralysis.  Jessen  (and  his  observations  have  been  confirmed  by  several 
others)  obtained  better  results,  especially  in  cases  of  long  standing, 
amongst  females.  It  would  therefore  appear  that  in  the  opposite  sex  a 
•state  of  incurability  sets  in,  on  an  average,  at  an  earlier  date.  AVitli 
regard  to  cases  of  hereditary  insanity,  there  is  a  preconceived  and  all  but 
universal  opinion  that  the  prognosis  is  absolutely  hopeless;  hence  the  fre- 
quent neglect  of  the  necessary  therapeutic  measures.  But  the  numbers 
of  such  cases  that  have  been  successfully  treated  are  sufficient  to  establish 
the  fact  that  hereditary  taint  does  not  constitute  a  case  incurable;  still 
the  chances  of  recovery  are  but  slight,  and  even  when  it  has  taken  place 
there  is  great  danger  of  relapse.  As  to  whether  patients  from  the  upper 
ranks  of  society,  of  good  education  (as  has  been  asserted),  present  greater 
chances  of  cure  than  those  from  the  lower  classes — whether  recoveries  are 
of  rare  occurrence  amongst  Jews,  etc. — are  subjects  upon  which  I  must 
confess  my  inability  to  give  a  definite  opinion.  The  natural  disposition, 
acquired  peculiarities  of  character,  the  degree  of  strength  of  mind,  the 
ease  or  difficulty  with  which  the  patient  yields  to  the  malady  or  to  the 
curative  influences,  are  points  of  the  greatest  value  in  prognosis.  Diseases 
which  have  been  gradual  in  their  development,  occurring  in  persons  who 
have  been  remarkable  from  youth  upwards  for  their  excessive  capricious- 
ness,  their  originality  of  taste  and  eccentricity  of  character,  are  serious 
in  every  point  of  view.  Equally  unfavorable  are  cases  originating  after 
long  and  painful  emotions,  years  of  vexation,  prolonged  suspense  between 
hope  and  doubt  ended  by  disappointment,  after  intense  passion  causing 
mental  devastation.  These  deep  wounds  do  not  heal  without  loss  of  cere- 
bral substance;  they  are  often  followed  by  complete  derangement  of  the 
mental  constitution,  and  in  such  cases  the  chances  of  recovery  are  far  less 
than  in  those  resulting  from  a  sudden  mental  shock — a  fright,  etc. 

The  primary  idiopathic  affections  of  the  brain  are,  generally  speaking, 
much  more  serious  than  the  secondary  and  sympathetic.  Mental  diseases 
following  upon  injury  to  the  head,  acute  meningitis,  sanguineous  apo- 
plexy, and  long-standing  epilepsy,  especially  the  two  latter,  are  almost 
absolutely  incurable  (still  there  are  exceptions);  and  the  same  may  be 
said  of  those  which  have  made  their  appearance  after  typhus  fever  and 
become  chronic.  On  the  other  hand,  anaemia,  acute  congestion  of  the 
brain,  indigestion,  menstrual  and  many  other  derangements  of  the  sexual 
21 


322  TKOGKOSIS. 

organs,  are  amongst  the  physical  states  which  contribute  to  the  develop- 
ment of  mental  diseases  of  more  favorable  prognosis.  In  insanity  result- 
ing from  inveterate  drunkenness,  the  prognosis  is  most  unfavorable;  it 
early  assumes  the  character  of  mental  weakness.  Where  it  originates 
from  more  moderate  intemperance,  the  case  may  be  considered  curable, 
but  there  is  an  extraordinay  tendency  to  relapse.  Onanists,  and  those 
exhausted  by  sexual  excesses,  are  not  to  be  considered  incurable  so  long 
as  the  cause  can  be  removed,  the  general  health  improved,  and  any  exist- 
ing local  disease  successfully  treated.  Eecovery,  -on  the  other  hand,  is 
impossible  where  monomania  has  set  in,  and  particularly  where  the  patient 
has  hallucinations  referring  to  personal  intimacy  of  the  most  debased  kind 
with  the  supernatural,  together  with  a  tendency  to  masturbation.  Hys- 
terical insanity,  acute  in  its  outbreak  and  with  violent  agitation,  is  of 
better  prognosis  than  when  it  is  passive,  characterized  by  depression,  and 
slow  in  its  course.  Of  all  the  forms  of  insanity,  puerperal  mania  is  that 
in  which  the  prognosis  is  most  favorable.  In  asylum  practice  this  form 
stands  high  in  the  ratio  of  curability,  although  the  majority  of  such  cases 
do  not  enter  these  institutions,  but  are  successfully  treated  at  home. 

The  external  circumstances  and  relations  of  life  of  the  patient  greatly 
influence  the  prognosis.  Where  effective  treatment  is  limited  by  poverty 
or  other  untoward  circumstance,  where  the  obstinacy  or  prejudice  of 
relatives  prevents  timely  interference,  or  where  removal  from  those  scenes' 
of  life  is  rendered  impossible  in  the  midst  of  which  the  mental  malady 
arose,  and  from  whence  it  constantly  derives  new  vigor,  no  false  illusions 
need  be  built  regarding  the  possibility  of  cure;  nothing  can  here  be 
expected  from  nature,  whose  efforts  are  thus  rendered  ineffectual. 

§  201.  A  consideration  of  the  chances  of  recovery  in  insanity  affords, 
upon  the  whole,  very  gratifying  results.  From  the  statistics  of  institu- 
tions for  the  insane,  it  appears  that  recent  mental  disease  allows  of  a  far 
better  prognosis  than  most  other  chronic  affections  of  the  brain.  If  we 
understand,  however,  the  word  ''recovered''  to  signify,  as  it  ought,  the 
total  disappearance  of  the  mental  disease — the  complete  return  of  the 
former  capacity  of  intellect,  of  the  whole  earlier  force  of  character,  it 
must,  of  course,  be  but  seldom  that  such  a  result  can  be  expected.  Cases 
are  by  far  more  numerous  where,  indeed,  the  leading  symptoms  of  the 
insanity  disappear,  but  the  individual  retains  a  slight  feebleness  of  intel- 
lect, continues  irritable  in  temper,  has  occasional  tics,  or  is  possessed  of 
certain  eccentricities,  which,  however,  permit  him  to  take  part  in  the 
simple  avocations  of  life,  and,  it  may  be,  to  return  to  his  former  pursuits. 
Hence  a  distinction  ought  to  be  made  in  successfully  treated  cases  between 
recovered  and  improved,  as  has  long  been  the  practice  in  many  well-regu- 
lated institutions,  such  as  Winncnthal. 

It  is  evident  that  by  such  improvement  is  to  be  understood,  not  only  a 
state  of  outward  calm,  but  an  essential  alteration  comprehending  the 
complete  arrest  of  the  further  progress  of  the  disease.  It  would,  for 
example,  be  wholly  inadmissible  to  declare  that  a  maniac  whose  disease 
had  gradually  verged  into  dementia,  and  who  was  now,  as  a  consequence, 
quiet  and  inoffensive,  and  could  even  be  kept  in  private  circumstances, 
was  on  that  account  improved.  Such  a  case  has,  on  the  contrary,  become 
in  reality  aggravated,  and  can  only  be  dismissed  from  the  asylum  as  no 
longer  curable. 

It  may  be  here  permitted  to  give  a  few  quotations  from  the  statistics 
of  the  asylums  of  Germany.  Winnenthal  had  in  twenty  years  (1834-54) 
1424  admissions  (888  M.,  536  F.),  whereof   (here   were  445  recoveries: 


PROGNOSIS.  323 

(260  M.,  185  F.) — equal  to  31  per  cent.  Siegburg,  from  1st  October, 
1846,  to  31st  December,  1850,  872  patients,  277  recoveries — equal  to  31 
per  cent.  Sachsenburg,  in  ten  years  (1840-49),  695  admissions,  with  213 
recoveries — equal  to  30-31  per  cent.  From  Sonnenstein,  during  the  five 
years  1846-51,  there  were  dismissed  recovered  33  per  cent  of  those 
admitted.  These  results  correspond  in  a  remarkable  manner  with  one 
another;  and  when  Fleming  says  ('Ztschr.  f.  Psych.,'  xv.,  1858,  p.  8) — 
"It  is,  at  the  present  time,  satisfactorily  demonstrated  that  with  respect 
to  mental  diseases  no  statistics  exist  whereon  conclusions  may  be  founded 
regarding  the  curability  of  these  diseases,  or  the  efficacy  of  the  remedial 
means  employed," — I  quite  agree  with  him  in  the  latter  point,  but  lean- 
not  at  all  indorse  his  statement  regarding  the  curability  of  insanity. 

§  202.  The  mere  disappearance  of  the  more  striking  symptoms,  the 
cessation  of  the  fury  and  the  delirium,  cannot  be  regarded  as  certain  signs 
of  complete  return  of  mental  health.  The  patient  may  become  quiet  to 
all  appearance,  and  learn  to  conceal  many  false  notions  which  are  never- 
theless inwardly  cherished  by  him;  and  this  may  even  coincide  with  a 
striking  improvement  in  the  state  of  general  health.  The  most  impor- 
tant symptoms  of  really  returning  sanity  are  rather  the  distinct  appre- 
ciation of  the  mental  disease  by  the  patient,  the  discernment  of  the 
abnormality  of  the  former  state,  the  parting  with  all  its  accompanying 
delusions,  and  the  impartial  estimation  of  the  present  position  from  every 
poinb  of  view.  With  these  must  be  associated,  a  return  to  former 
tastes  and  to  normal  habits,  of  the  instinct  for  vital  activity,  of  interest 
in  the  former  affairs  of  life,  of  that  affection  towards  family  and  friends 
so  often  changed  to  hatred  during  the  disease.  Just  as  the  insanity 
commenced  with  perverted  dispositions  and  emotional  states,  so  it  is  this 
phase  of  psycliical  life  that  is  specially  to  be  looked  to  in  its  disappear- 
ance. When  at  length  the  intelligence  appears  unimpaired,  but  where 
abnormal  aversions  still  exist  toward  certain  individuals,  or  a  vague  state 
of  sullen  anger  and  passion,  or  perhaps  merely  a  state  of  psychical  exal- 
tation, is  retained,  which  renders  the  patient  very  irritable;  so  long  as 
the  patient  cannot  bear  any  reference  to  his  former  malady,  and  solici- 
tously shuns  everything  tliat  may  recall  it — where,  in  a  word,  anything 
strange  it  still  observable  in  his  feelings,  demeanor,  speech,  physiognomy 
or  glance — we  cannot  say  that  full  recovery  has  taken  place.  The  foun- 
dation of  recovery  is  rather  a  perfect  quietness  of  mind;  the  individual 
who  is  radically  cured  speaks  freely  of  his  malady  to  those  around,  and 
especially  to  the  physician,  as  of  something  which  has  now  become  quite 
foreign  to  him.  He  expresses  almost  always  thankfulness  and  confidence, 
but  never  boisterous  joy,  at  his  recovery,  and  leaves  the  date  of  his  dis- 
missal from  the  asylum,  without  trying  to  hasten  it,  entirely  to  the  dis- 
cretion of  the  physician. 

Those  recoveries  which  take  place  gradually,  with  steadily  progressing 
consciousness  of  the. internal  malady,  are,  generally  speaking,  more  last- 
ing than  rapid  and  sudden  improvements,  even  though  they  may  appear 
quite  as  complete.  On  the  one  hand,  there  may  exist  from  the  psychical 
aspect  the  most  favorable  signs  of  complete  recovery;  while,  on  the  other 
hand,  physical  diseases  (such  as  tuberculosis,  diseases  of  the  genital 
organs,  etc.),  which  had  evidently  exerted  an  influence  upon  the  devel- 
opment of  the  mental  disease,  remain  unhealed.  In  such  cases,  the  ver- 
dict of  full  recovery  from  the  insanity  need  not  be  delayed  till  the  re- 
storation of  bodily  health;  but,  at  the  same  time,  the  great  danger  of  new 
and  repeated  mental  disease  must  be  kept  in  view.     In  all  these  cases,  a 


324;  PROGNOSIS. 

certain  duration  of  the  psychical  feeling  of  wellbeing  is  required  to  dis- 
tinguish permanent  recovery  from  mere  lucid  interval — just  as  we  would 
not  pronounce  a  case  of  epilepsy  to  be  cured  after  months  even  of  free- 
dom from  the  attacks,  but  first  wait  for  a  longer  period  the  full  confirm- 
ation of  our  favorable  opinion. 

Some  observers  (Esquirol)  were  disposed  to  consider  only  those  cases 
of  recovery  as  sufficiently  certain  which  were  accompanied  by  a  well- 
marked  crisis;  others  (Jessen,  C.  G.  Neumann,  and  ourselves)  have, 
upon  the  whole,  very  seldom  observed  such  crises.  We  do  not  deny  that 
those  constitutional  changes  which  must  frequently  accompany  recovery 
from  such  a  serious  disease  may  occasionally  be  announced  by  increased 
quantity  or  altered  quality  of  the  excretions,  by  the  appearance  of  skin 
eruptions,  etc.,  and  that,  to  a  certain  extent,  a  favorable  interpretation  is 
due  to  those  events  when  they  occur  coincidently  with  mental  improve- 
ment. These  phenomena  appear,  however,  more  frequently  as  results 
than  as  causes  of  the  recovery;  very  often  they  are  wholly  accidental  oc- 
currences, and  the  fact  of  their  frequent  comjilete  absence  would  of  itself 
sufficiently  refute  the  opinion  of  Esquirol. 

§  203.  The  proportion  of  the  permanent  recoveries  must  be  estimated 
by  the  number  of  relapses.  Jacobi  estimates  that,  of  100  recoveries,  about 
25  are  readmitted.  Parchappe  gives  164  relapses  in  498  recoveries. 
Farr,  for  the  English  county  asylums,  gives  1200  relapses  in  5486  recov- 
eries (more  than  one-fourth).  Julius,  for  the  York  Eetreat,  makes  the 
official  statement  of  31  relapses  to  100  recoveries;  he,  however,  considers 
the  actual  proportion  to  be  much  higher.  Damerow  had  in  Halle  14  per 
cent.  Guislain  estimates  19  per  cent  as  the  proportion  in  asylum  prac- 
tice: this  number  is  also  given  for  the  asylums  of  Holland  (Schroder  van 
der  Kolk).  But  all  the  cases  of  relapse  do  not  again  enter  the  asylum  to 
be  treated;  we  must,  therefore,  accept  a  higher  number,  from  20  to  25 
per  cent,  as  the  proportion  of  the  once  recovered  who  again  become 
insane. 

Eelapses  occur  by  far  most  frequently  during  the  first  and  second 
years  after  recovery.  This  is  easily  accounted  for  by  the  state  of  exalted 
psychical  irritability,  which  often  continues  for  some  time  after  the  dis- 
appearance of  the  disease,  and  the  greater  susceptibility  to  physical  ail- 
ments which  must  exist  after  so  serious  a  malady.  Too  early  dismissal 
from  the  asylum  is  likewise  a  frequent  cause.  To  the  first  of  these 
causes  is  also  probably  due  the  fact  that  relapses  are  somewhat  more  fre- 
quent in  the  female  sex  (Schroder  van  der  Kolk  and  Parchappe).  It 
should  be  remembered,  too,  how  rare  complete  and  lasting  recoveries  are 
in  most  chronic  diseases,  and  how  difficult  it  is  to  remove  certain  consti- 
tutional causes  which  may  frequently  have  existed  from  earliest  infancy, 
whose  constant  action  has,  as  a  consequence,  a  succession  of  diseases  fol- 
lowing the  same  pathological  direction.  It  is  not  to  the  powerlessness  of 
our  art,  nor  to  a  certain  predestinated  incurability  of  these  forms  of  dis- 
ease, that  we  ascribe  relapses  in  those  who,  on  their  dismissal  from  the 
asylum,  return  to  the  most  deplorable  conditions  of  life,  or  to  the  full 
influence  of  those  health-destroying  causes  which  were  to  blame  for  their 
first  attack.  In  the  case  of  individuals  who,  on  recovery,  return  to  habits 
of  drunkenness,  to  misery,  to  over-fatiguing  employments,  to  the  causes 
of  violent  agitations  and  emotions,  we  can  almost  with  certainty  predict 
a  relapse;  the  drunkard,  especially,  is  each  time  dismissed  from  the  asy- 
lum only  with  the  unsatisfactory  prospect  of  soon  seeing  him  again. 
Upon  the  whole,  however,  the  prospects  of  recovery  in  insanity  are  much 


PROGNOSIS.  325 

brighter  than  is  generally  supposed  by  medical  men  and  the  public.  At 
all  events,  we  may  confidently  assert  that  the  prognosis  in  recent  acute 
insanity  is  very  much  more  favorable  than  in  most  other  diseases  of  the 
brain,  especially  than  in  the  various  forms  of  epilepsy. 


326  THEiiAPEUTICS. 


CHAPTEE  II. 
THERAPEUTICS. 

Section  I. — General  Principles. 

§  204.  The  treatment  of  mental  diseases  has,  in  a  very  abundant 
measure,  experienced  the  power  of  theoretical  hypotheses,  and  the  alter- 
nating influence  of  one-sided  systems.  The  old  humoral  pathology 
taught,  and  till  very  recently,  the  elimination  of  black  bile;  the  excita- 
tion theory  sought,  and  still  seeks,  the  increase  or  diminution  of  the 
action  of  the  exciting  powers;  and  the  followers  of  the  theory  of  local- 
ized inflammation  profess,  although  in  opposition  to  every-day  experi- 
ence, the  ordinary  antiphlogistic  method  as  the  basis  of  their  treatment. 
Mental  medicine  had,  more  than  this,  an  addition  of  its  own  to  contend 
with  in  the  moralizing  ideas  that  were  held  by  bigots  regarding  the 
treatment  of  insanity.  One  great  principle,  however,  pervades  the  whole 
system  of  modern  psychiatry — the  great  principle  of  humanity  in  the 
treatment  of  the  insane,  in  contradistinction  to  that  former  barbarism 
which  sometimes  persecuted  the  mentally  afflicted  Avith  trials  for  sorcery 
and  death  at  the  stake;  sometimes,  and  this  in  the  most  favorable  cases, 
cast  them  into  dungeons,  to  be  associated  with  criminals,  where,  beyond 
the  influence  of  the  medical  art,  and,  deprived  of  all  human  aid,  they 
were  consigned  to  the  realms  of  despotic  cruelty  and  brutality.  Cer- 
tainly, it  was  that  forced  acknowledgment  of  insanity  to  be  a  disease — 
next  to  this,  however,  and  mainly,  it  was  that  philanthropy  which  vindi- 
cated the  claims  of  the  insane  from  the  stand-point  of  the  common  rights 
of  humanity — that  first  achieved  their  recognition  as  human  beings  by 
society,  towards  whom  protection  and  help  was  due;  that  they  more  and 
more  become  the  objects  of  earnest  guardianship  by  the  State,  and 
of  earnest  scientific  research,  whose  aim  is  their  cure.  The  retrospect  of 
former  times,  and,  above  all,  of  the  labors  of  Pinel,  must  be  pleasing  and 
elevating  to  the  minds  of  all  of  us.  That  great  principle  of  humanity  is 
now  placed  beyond  all  possibility  of  dispute,  and  if  we,  as  physicians, 
allow  our  practice  to  be  governed  by  it,  we  do  that  which  tends  more 
than  anything,  on  account  of  its  emj^irical  results,  towards  arriving  at  our 
first  and  only  aim — the  recovery  of  the  patient;  results  regarding  whose 
incomparable  superiority  to  the  experiences  of  former  times  no  further 
proof  is  necessary.  It  is  not  the  glitter  of  an  abstract  principle  of  phil- 
anthropy, however,  that  must  guide  us;  it  is  practical  utility — the 
results  of  suitably  directed  treatment  at  the  bedside  of  the  patient,  or  in 
the  cell  of  the  maniac.  For  this  reason,  also,  we  must  acknowledge 
these  humanitarian  principles  as  rules  of  treatment  only  in  so  far  as  they 
further  our  aim;  we  must  remember  that  that  treatment  is  not  always  the 
most  humane  which  best  accords  with  the  particular  sentiments  of  the  phy- 
sician, or  is  most  agreeable  to  the  feelings  of  the  patient,  but  that  which 
worhs  a   cure.     Psychiatry,   then,   should  never  degenerate   from   the 


THERAPEUTICS.  327 

gravity  of  a  practical  science  into  a  system  of  sentimentality,  such  as  even 
laymen  could  scarcely  be  found  to  defend. 

§  205.  In  the  first  place,  it  has  so  come  about,  from  the  fact  of 
results  arrived  at  through  experience,  that  both  the  psychical  and  somatic 
methods  of  treatment  are  equally  entitled  to  a  precisely  similar  amount  of 
our  attention.     Both   modes  of  acting  upon  the  patient  have  always 
instinctively  been  combined,   and  the  most  narrow-minded  moralistic 
theory  cannot  possibly  dispute  the  efficacy  of  properly  directed  medica- 
ments— baths,  etc.;  while,  at  the  same  time,  everyday  experience  has 
shown  that  almost  no  recovery  can  be  perfected  without  psychical  reme- 
dies (which  may  only  consist  of  work,  discipline,  etc).     In  spite,  how- 
ever of  the  practical  utility  of  this  method,  theoretical  hypotheses  have 
rendered  it  difficult  for  science  to  recognize  the  results  of  experience — 
the  call  for  an  undelayed  combination  of  mental  and  physical  remedies  in 
mental  disease  on  the  ground  of  its  necessity.     Can  deviations  of  the 
power  of  thought,  it  has  been  ironically  demanded,  be  corrected  by  the 
thinning  of  an  atrabilious  blood  or  by  the  solution  of  stagnant  fluids  in 
the  portal  system?    Shall  mental  pain  be  combated  with  sneezing-pow- 
ders, and  perverted  witticisms  with  clyster-tubes?    The  votaries  of  phy- 
sical treatment,  on  the  other  hand,  urge  the  influence  of  the  bodily 
states  upon  that  of  the  mind;  they  appeal  to  the  cases  in  which — ay, 
quite  evidently — insanity  has  been  cured  by  digitalis,  camphor,  etc. ;  and, 
as  generally  happens  in  such  cases,  science,  which  aims  above  all  things 
at  unity  and  consistency  of  principle,  satisfies  in  the  end  both  parties,  by 
the  eclectic  admission  that  in  individual  urgent  cases  either  the  one  or 
the  other  system  of  therapeutics  must  become  secondary  or  assisting 
treatment  to  the  other  or  chief  plan  of  treatment.     So,  with  the  one 
party,  psychical,  with  the  other  somatic,  treatment  plays,  in  comparison 
to  the  importance  of  the  principal  plan  of  treatment,  only  a  subordinate 
and  meagre  part.     But  to  understand  the  necessary  equal  right  of  both 
methods,  it  may  be  remembered,  in  the  first  place,  that  all  psychical  acts, 
normal  or  abnormal,  are  cerebral  phenomena,  and  that  cerebral  activity 
may  be  modified  quite  as  effectually,  directly,  and  immediately  by  the 
evocation  of  frames  of  mind,  emotions,  and  thoughts,  as  by  diminishing 
the  quantity  of  blood  within  tlie  cranium,  or  by  modifying  the  nutrition 
of  the  brain,  as,  for  example,  by  narcotics  and  excitants.     The  fact  that 
medicines  proved  empirically  to  be  effectual  have  been  employed  in  insan- 
ity, as  in  other  diseases  of  the  brain,  requires  no  vindication;  the  fre- 
quent success  of  psychical  treatment,  too,  in  cases  where  palpable  organic 
lesions    had    influenced   the    development    of    the    mental    disease,    is 
explained  by  the  influence  which  the  brain  exerts  upon  other  organic  pro- 
cesses: we  have,  therefore,  a  very  powerful  means  of  successfully  modify- 
ing indirect  disturbances  of  the  somatic  state  (of  the  circulation,  the  diges- 
tion, etc.)  in  the  direct  provocation  of  certain  states  of  mind.     It  is  true 
that  serious  disorganizations  of  the  brain  (as  imbecility  with  paralysis) 
render  (of   course)  all  moral  influences  impossible;  but  we  know  that 
insanity,  at  its  commencement,  consists  very  frequently  of  mere  func- 
tional derangement,  and  that  anatomical  changes,  if  slight,  do  not  ren- 
der the  success  of  moral  treatment  altogether  impossible,  provided  tliat 
the  organs  are  capable  of  accommodation  to  a  certain  extent  to  their 
respective  functions;  and  the  success  which  in  recent  times  has  attended 
many   attempts,    even   in  idiocy,    and   where   the  brain  was  defective, 
demonstrates  that  the  skilful  use  of  appropriate  means  renders  possible 
a  certain  development  of  the  understanding.     From  this  point  of  view, 


328  THERAPEUTICS. 

the  treatment  of  insanity  appears  to  be  eminently  personal;  it  is  simul- 
taneously directed  to  the  physical  and  mental  nature  of  the  individual, 
and  when,  in  the  following  chapters,  we  speak  in  detail  of  the  psychical 
and  somatic  as  distinct  modes  of  treatment,  the  fact  of  their  intimate 
relation  to  one  another  cannot  but  be  very  evident. 

§  206.  If  the  treatment  of  mental  diseases  (especially  the  physical) 
agrees  in  a  great  measure  with  the  principles  and  practice  of  ordinary 
therapeutics,  so  also  can  we,  with  the  greatest  possible  clearness  and 
cogency,  prove  that  several  special  claims  are  due  to  our  department  in 
every  rational  method  of  medical  treatment.  Nowhere  is  the  desideratum 
strictly  to  keep  in  view  the  individual  of  greater  importance  than  in  the 
treatment  of  insanity;  nowhei'e  is  the  constant  consciousness  more  neces- 
sary that  it  is  not  a  disease,  but  an  individual  patient — that  it  is  not 
mania,  but  an  individual  who  has  become  maniacal — that  is  the  object  of 
our  treatment.  Each  individual  case  should  be  specially  investigated  in 
all  its  bearings,  which  constantly  vary,  and  all  the  means  of  anatomical 
diagnosis  and  pathological  research  ought  to  be  brought  to  bear  upon  its 
elucidation;  in  fact,  a  penetration  into  the  psychical  individuality  of  the 
patient  is  here  demanded,  which  is  scarcely  ever  necessary  in  ordinary 
medical  practice.  Hence  follows,  on  the  one  hand,  the  practical  rule 
(urgent  measures  in  cases  of  sudden  accident  excepted),  that  in  no  case 
should  active  treatment  be  commenced  without  previous  careful  inquiry 
into  the  previous  history  of  the  patient  and  the  origin  of  the  disease,  and 
towards  which  all  those  special  requisites  have  not  been  fulfilled  which  have 
been  already  spoken  of  in  page  94  as  constituting  the  first  duties  of  the 
physician  in  the  treatment  of  mental  disease.  It  follows,  therefore,  that 
there  is  a  degree  of  variety  in  the  practical  treatment  of  the  insane  which 
cannot  be  explained  in  detail  in  a  treatise  such  as  this,  and  of  which  we 
can  only  lay  down  and  specify  the  general  principles  of  treatment. 

There  is  one  point  in  the  treatment  of  insanity  which  requires  to  be 
sjjecially  noted — the  necessity  of  vigorous  interposition  on  our  part  to 
prevent  its  assuming  the  chronic  type;  interference  at  the  earliest  possi- 
ble period,  at  the  very  commencement  of  the  malady,  and  even  before  its 
full  development  is  necessary:  what  has  already  been  said  under  the  head 
of  prognosis  (§  199)  will  have  sufficed  to  establish  this  point.  But,  on 
the  other  hand,  after  it  is  fully  developed,  nothing  is  more  to  be  avoided 
than  impatience  and  over-officiousness  in  treatment.  We  must  remem- 
ber that  the  ordinary  course  of  mental  diseases,  even  in  favorable  cases, 
is  slow;  we  have  to  reckon  by  months  and  by  years;  we  must  wait,  and 
learn  to  take  advantage  of  favorable  periods,  which  are  often  late  in  be- 
ginning to  make  their  appearance.  We  must  seek  carefully  to  oppose 
each  sym^Dtom  of  the  malady,  and  every  indication  of  the  delirious 
thoughts;  and  by  a  continuous  and  minute  observation  and  strict  superin- 
tendence of  the  patient,  we  can,  in  many  cases,  anticipate  a  favorable 
issue  without  the  use  of  active  measures. 

In  mental,  as  in  many  other  diseases,  the  simple  expective  and  dietetic 
treatment — which  is  so  far  removed  from  meriting  the  absurd  reproach  of 
the  do-nothing — is  in  many  cases,  though  not  in  all,  far  in  advance  of 
the  employment  of  very  active  and  often-changed  remedies.  To  how 
small  an  extent  their  recovery  is,  properly  speaking,  due  to  direct  medi- 
cinal interference,  is  seen  from  the  similarity  of  statistics  furnished  by 
various  asylums  where  the  methods  of  treatment  are  essentially  different 
(see  page  331).  It  has  been  now  long  admitted  that  mental  diseases  are 
not  to  be  cured  by  any  special  method  of  treatment;  a  conclusion  based 


THERAPEUTICS.  329 

on  the  fact  that  in  the  two  sections  of  the  Bicetre,  where  then  directly 
opposite  methods  were  followed,  the  results  as  to  recovery  were  exactly 
similar. 

§  207.  Indeed,  observation  shows  that  very  many  cases  of  recent  dis- 
ease proceed  spontaneously  to  recovery,  without  much  positive  interfer- 
ence, through  a  treatment  limited  to  the  warding  off  of  all  injurious 
influences.  In  relation  to  this,  the  causal  indication  next  presents  itself; 
the  removal,  so  far  as  we  can,  of  those  causes  by  whose  united  influence 
the  disease  has  arisen.  And  if  the  etiology,  as  it  may,  exhibits  here 
many  important  points  the  removal  of  which  is  not  within  the  province 
of  the  pnysician  (compare  the  second  book),  still,  to  dissolve  that  mutual 
connection  out  of  which  the  disease  has  arisen,  it  is  often  sufficient  to  do 
away  with  some  of  these  injurious  influences,  whether  concurrent  physical 
diseases,  or  unfavorable  psychical  states.  We  should,  therefore,  in  the  first 
place,  always  try  to  discover  means  and  ways  to  withdraw  the  patient  from 
those  influences  to  which  his  disease  is  traceable.  The  means  are  various 
enough;  the  removal  of  physical  causes  (§  102-109)  does  not  differ  from 
the  treatment  ordinary  in  these  conditions:  special  attention  must  be  paid 
to  all  that  might  cause  a  determination  of  blood  to  the  head;  so  also  every- 
tliing  that  might  excite  nervous  irritation,  whether  through  direct  super- 
excitation  of  the  brain,  or  disordered  general  nutrition  and  physical  frame, 
or  through  exhaustion  of  any  kind,  must  be  rectified.  The  removal  of 
psychical  causes  consists  mainly  in  the  simple  prevention  of  their  further 
effects,  and  in  the  temporary  withdrawal  of  the  patient  from  their  influ- 
ence. This,  in  general,  can  be  done  only  hj  a  complete  change  of  his 
external  condition  through  separation  from  his  former  domestic  relations, 
more  particularly  if  he  continually  finds  in  them  new  sources  of  emotion 
and  vexation;  where,  too,  the  patient  is  altogether  unaware  of  the  delete- 
rious influence  of  these  circumstances,  he  must  be  withdrawn,  at  any 
price,  from  the  continuous  repetition  of  the  impressions  which  engendered 
the  disease.  This,  to  a  great  extent,  coincides  with  the  important  condi- 
tion of  carefully  regulating  the  rest  and  activity  of  the  brain  (see  following 
section),  a  key  to  the  knowledge  of  the  whole  system  of  mental  therapeu- 
tics. 

The  prophylaxis  of  mental  disease  is  seldom  the  subject  of  medical 
consultation.  By  its  means  insanity  could  doubtless  be  to  some  extent 
diminished,  as  marriages  might  be  prevented  betwixt  members  of  a 
family  who  were  manifestly  predisposed  to  mental  disease.  "With  refer- 
ence to  individual  prophylaxis,  much  depends  upon  a  well-regulated 
system  of  mental  and  physical  diet.  During  the  period  of  early  education, 
all  stimulus  of  the  mental  faculties  must  be  avoided,  and  the  development 
of  the  physical  powers  as  mucli  as  possible  encouraged.  Everything  tend- 
ing to  predominance  of  the  imagination — physical  weakness  and  effemi- 
nacy of  disposition,  or  early  sexual  development — must  be  withdrawn. 
Care  must  be  taken  that,  to  the  utmost  possible  extent,  the  external 
uffairs  of  life  are  simple  and  methodical,  continuous  states  of  passion 
avoided,  and  habits  of  subordination  instilled  into  the  child.  These,  as 
lias  been  justly  remarked  by  Flemming,  are  not  intended  as  mere  abstract 
rules  of  good  behavior  which  are  of  but  little  weight  when  the  mind  is 
deeply  agitated  by  stormy  passions;  the  power  of  resisting  sorrow  and 
emotion  depends  most  of  all  upon  a  vigorous  and  powerful  organization, 
and  therefore  upon  a  sound  state  of  physical  health  and  careful,  unre- 
mitting attention  to  the  removal  of  all  diseases  which  have  a  tendency 
towards  chronicity.     The  means  employed  towards  arriving  at  this  re- 


330  THERAPEUTICS. 

suit,  being  chiefly  hygienic,  must  necessarily  vary  in  each  individual 
case. 

§  208.  In  mental  diseases,  as  in  all  other  derangements  of  the  organ- 
ism, a  duly  regulated  measure  of  repose  and  activity  is  amongst  the  most 
important'means  of  treatment.  In  every  case,  if  acute  and  recent,  the 
primary  indication  is  absolute  rest  of  the  brain,  the  suppression  of  all  ac- 
customed irritation,  and  still  more  of  all  stronger  or  positively  injurious 
influences.  The  patient  instinctively  seeks  this  rest;  he  withdraws  him- 
self from  every  cheerful  expression,  from  all  bustle,  fatiguing  conversa- 
tion, and  everything  that  would  be  painful  to  him;  he  seeks  solitude. 
So,  when  an  individual  falls  into  melancholia,  all  attempts  to  resist^  it 
by  external  distraction  are  useless  or  injurious.  From  loud  and  noisy 
amusements  especially,  the  patient  can  receive  now  only  painful  impres- 
sions; it  is  still  more  injurious  to  ply  him  with  impressive  exliortations, 
queries,  and  admonitions.  The  mental  activity  to  which  he  was  accus- 
tomed is  now  a  source  of  irritation;  and  only  retreat  from  the  accustomed 
sphere  of  life,  solitude,  and  perfect  rest  of  the  brain,  can  act  beneficially 
upon  those  on  whose  minds  everything  produces  too  great  agitation.  This 
object  may  be  attained,  according  to  the  requirements  of  the  case  and  its 
outward  circumstances,  through  removal  to  retired  and  peaceful,  and  afc 
the  same  time  agreeable  and  pleasant  associations;  or  through  the  strictest 
seclusion,  and  sometimes  even  through  prevention  of  all  impressions  of 
sound  and  light;  the  latter  especially  in  conditions  of  recent  exaltation, 
and  sometimes  in  melancholia,  at  its  commencement  and  climax.  As, 
however,  in  most  diseases,  a  period  ensues,  after  the  termination  of  the 
acute  stage,  in  which  the  organ  gradually  resumes  its  function,  and  can 
only  regain  its  normal  power  through  a  return  of  well-directed  activity; 
so  here,  too,  there  are  periods  where  a  further  prolongation  of  deep  still- 
ness would  be  injurious,  and  where  a  new  impetus  in  the  normal  direc- 
tion is  necessary  to  tlie  psychical  life  to  secure  it  against  cessation  and  de- 
chne.  In  those  already  convalescent,  this  requisite  appears  of  its  own 
accord;  but  in  very  many  cases,  at  the  termination  of  the  acute  stage, 
and  on  entry  of  a  state  of  quiet,  it  must  be  first  awakened — aye,  energeti- 
cally aroused.  From  custom,  the  patient  often  continues  to  struggle 
against  this  healthy  mental  excitation,  and  still  more  against  healthful 
self-exertion;  while  he  nevertheless,  chiefly  through  the  resumption  and 
practice  of  his  power,  can  regain  his  former  strength  and  healthy  tendency, 
and  many  do  not  recover  while  energetic  interference  was  neglected  in 
this  often  short  and  always  invaluable  period.  Thus,  while  with  some 
such  this  object  can  be  effected  through  agreeable  sensuous  impressions, 
visiting,  re-entrance  into  society,  light  employments,  etc.,  with  others 
something  like  compulsion  is  often  needful  to  rouse  them  from  their 
mental  torpor,  and  the  whole  range  of  mental  therapeutics  is,  in  such 
cases,  especially  to  be  employed. 

It  appears  once  more  that  the  general  principles  of  treatnient  in  in- 
sanity correspond  in  a  remarkable  manner  with  the  means  which  experi- 
ence has  shown  to  be  useful  in  other  nervous  affections.  In  all  states  of 
acute  irritation  of  any  portion  of  the  nervous  system,  we  permit  the 
strictest  observance  of  that  quiet  which  is  instinctively  sought  by  the 
patient.  In  many  clironic  nervous  diseases,  on  tlie  other  hand  (for  ex- 
ample, conditions  of  muscular  weakness),  we  pay  no  heed  to  the  sensation 
of  weakness  felt  by  the  patient;  we  know  that  it  is  rather  by  combating 
this  sensation,  so  that  he  has  frequently,  at  the  commencement,  to  be 
half  compelled  to  resume  muscular  action  and  exertion,  that  the  normal 


THERAPEUTICS.  331 

innervation  will  again  be  ushered  in  and  established.  Brodie  has  repeat- 
edly called  attention  to  this  point  in  the  treatment  of  neuralgic  and  sub- 
paralytic  conditions  of  the  extremities. 

§  209.  A  very  extended  experience  has  shown  that  the  above-men- 
tioned requisites  (§§  207,  208)  can,  for  the  most  part,  only  be  comi)lied 
with  by  totally  changing  the  occupations  of  the  patient,  by  entirely  re- 
moving him  from  his  usual  neighborhood,  and  by  exposing  him  to  the 
influence  of  new  and  perfectly  different  impressions. 

In  rare  cases  only  is  a  simple  change  of  residence,  or  a  sojourn  in 
some  quiet  and  agreeable  part  of  the  country,  at  all  useful.  More  pro- 
longed travelling,  which  in  the  milder  cases  of  hypochondria  is  often  of 
the  greatest  advantage,  although,  generally  speaking,  only  attainable  by 
the  more  wealthy,  is  in  all  severer  and  more  confirmed  cases  of  insanity 
wholly  inadmissible.  It  tends  usually  only  to  increase  tbe  excitement, 
and  the  most  serious,  perplexing,  and  dangerous  scenes  which  have  oc- 
curred in  our  experience,  have  been  those  in  which  mania  has  come  on 
after  such  "pleasure  tours;"  and  justly  does  it  recall  to  one's  memory 
the  old  saying,  that  a  man  cannot,  by  travelling,  or  by  change  of  abode, 
escape  either  from  himself  or  from  the  vexatious  burden  of  his  own 
thoughts. 

On  the  other  hand,  the  removal  of  a  patient  thus  situated  into  a  place 
specially  set  apart  for  the  reception  of  such  cases,  viz.,  into  a  good  luna- 
tic asylum,  is,  in  the  majority  of  instances,  the  treatment  which  is  most 
prominently  indicated.  It  is  above  all  things  necessary  for  the  safety  of 
the  patient  himself ;  for  iiowbere  else,  in  ordinary  circumstances,  is  he 
safe  from  the  obtrusiveness  and  injudicious,  though  often  well-meant,  in- 
terference of  his  friends;  and  nowhere  else  does  he  meet  with  that  indul- 
gent forbearance  which  springs  from  a  clear  understanding  of  his  case. 
The  relatives  of  the  patient  generally  regard  his  ever-increasing  ill-humor 
as  a  fault  which  he  might  readily  overcome  if  he  chose,  and  meet  it  with 
all  kinds  of  admonitions,  instead  of  with  ordinary  cbeerfulness  and  ap- 
peals to  his  reason;  if,  indeed,  they  do  not  look  upon  it  as  a  case  of  obsti- 
nate dissimulation,  and  punish  him  accordingly  with  harshness  and 
severity.  None  of  them  understand  the  patient;  indulgence  and  severity 
are  indiscriminately  and  wrongfully  employed:  consequently,  distrust 
arises  in  his  mind,  and,  as  the  result  of  this  treatment,  unpleasant  scenes 
and  struggles  occur,  which  not  only  irritate  the  patient  to  the  highest 
degree,  but,  by  the  recollection  of  them,  render  the  return  of  the  con- 
valescent to  his  home  peculiarly  difficult.  Particularly  in  famihes  where 
a  disposition  to  the  malady  has  already  manifested  itself,  a  careful  and 
complete  separation  is  naturally  the  first  step  to  be  adopted;  but  even 
-where  this  does  not  exist,  aversion  and  enmity  to  his  nearest  relatives  are 
often  excited  in  the  mind  of  the  patient  by  the  injudicious  treatment  to 
which  he  is  subjected  by  them,  and  on  this  account  the  most  complete 
isolation  is  demanded.  By  this  means,  too,  the  whole  current  of  his  ideas 
is  suddenly  interrupted  and  diverted  into  a  new  channel,  and  the  ten- 
dency to  the  ever-increasing  irritability  of  temper  is  successfully  resisted 
by  the  different  impressions  and  emotions  to  which  he  is  exposed.  How 
beneficial  in  these  circumstances  is  the  removal  of  the  patient  to  an  asy- 
lum, is  shown  by  the  fact  that  the  mere  idea  of  it  is  often  sufficient  to 
interrupt  the  progress  of  the  disease;  so  that,  in  a  few  cases  which  have 
been  till  then  in  the  highest  degree  unamenable  to  treatment,  not  only 
does  perfect  quiet  ensue,  but  even  the  most  decided  improvement  begins 
to  manifest  itself  from  the  very  moment  of  their  reception  into  the  asylum; 


332  THEKAPKUTICS. 

whilst,  indeed,  in  the  majority  of  cases  the  first  period  of  their  residence 
in  such  an  institution  is  marked  by  a  notable  remission  of  the  symptoms. 
Here  alone,  viz.,  in  the  asylum,  does  the  patient,  who  is  no  longer  able 
to  take  his  part  in  the  business  of  life,  find  everything  that  his  misfor- 
tunes require :  a  physician  well  acquainted  with  the  treatment  of  cases 
similar  to  his  own  ;  skilful  attendants  who,  as  well  as  all  about  him,  know 
how  to  treat  him  suitably  to  the  circumstances  of  his  case ;  an  asylum 
where  his  eccentric  behavior  is  concealed  from  over-officious  eyes,  where 
the  necessary  surveillance  is  unobtrusively  accorded  him,  and  where  he 
has  usually  a  far  greater  amount  of  freedom  than  he  could  possibly  have 
under  any  other  circumstances.  Here  he  can  weep  or  give  vent  to  his 
rage  by  himself,  if  necessary;  but  generally  speaking,  his  restless  habits, 
and  the  noisy  expression  of  his  maniacal  impulses,  are  materially  con- 
trolled by  the  example  of  the  other  patients,  and  by  the  ruling  spirit^  of 
peace  and  order  ;  he  is  brought  of  his  own  accord  into  the  quiet  routine 
of  the  house,  and  little  more  direct  coercion  is  necessary  to  overcome  any 
opposition  that  may  arise  than  the  singular  feeling  of  utter  powerlessness 
to  resist  the  overwhelming  authority  that  prevails  over  everything.  Here 
he  meets  with  forbearance  and  attention,  with  common  sense  and  words 
of  kindness;  he  feels  that,  in  conformity  with  the  circumstances  of  his 
case,  he  is  treated  as  an  actual  invalid;  and  he  also  observes  that  here  re- 
sistance is  utterly  useless,  and  soon  learns  to  submit  to  the  injunctions 
of  his  medical  attendant,  and  notices  that  his  whole  style  of  treatment, 
and  the  amount  of  liberty  and  enjoyment  accorded  to  him,  entirely  de- 
pend upon  his  condition,  and  the  degree  of  self-command  exercised  by 
him.  He  finds  here  the  essential  helps  to  self-government;  he  learns  again 
to  take  an  interest  in  things;  while,  simultaneously  with  this  care  for  his 
mental  improvement,  a  bodily  treatment,  by  means  of  a  regulated  diet, 
baths,  exercise  in  the  open  air,  medicine,  etc.,  can  be  constantly  and  sat- 
isfactorily carried  on.  In  this  manner  the  patient  becomes  conscious  of 
an  intelligent,  gentle,  and  constant  superintendence,  from  which  he 
gathers  confidence  and  hope;  and  the  sight  of  the  other  patients,  already 
well  and  fast  convalescing,  awakens  in  his  mind  the  hope  that  his  own 
health  will  also  be  re-established,  and  when  the  natural  longing  for 
return  to  his  home  again  springs  up,  generally  speaking,  the  patient 
leaves  it  with  entire  confidence  to  the  discretion  of  the  physician  to  fix 
the  date  of  his  dismissal. 

§  210.  Most  convalescents  bless  the  day  of  their  entrance  into  the 
asylum,  and  the  advantage  of  removal  to  such  an  institution,  first  most 
urgently  insisted  on  by  Esquirol,  has  since  then,  as  the  result  of  an  over- 
whelming experience,  been  established  as  a  fundamental  principle,  not 
only  in  psychiatry,  but  is  daily  becoming  more  and  more  recognized  as 
such  by  the  great  bulk  of  medical  men  generally,  as  well  as  by  the  laity 
themselves.  But  this  removal,  which,  on  the  one  hand,  when  certain 
indications  manifest  themselves,  cannot  be  too  soon  effected,  cannot  fail, 
on  the  other  hand,  to  exercise  a  very  important  infiuence  on  the  future 
career  of  the  patient  as  a  citizen,  and  is  a  step  which  always  demands  the 
gravest  consideration.  The  first  and  most  urgent  indication  for  this 
procedure  is  that  condition  of  the  patient  where  he  may  be  dangerous 
either  to  himself  or  to  others,  or  may  cause  any  great  disturbance;  the 
outbreak  of  mania,  or  unmistakable  signs  of  its  approach  are  manifested; 
a  tendency  to  commit  suicide,  the  prevention  of  which  in  private  can 
never  with  certainty  be  relied  upon;  and  refusal  of  food,  such  as  cannot 
be  easily  overcome.     Moreover,  all  cases  of  mania,  many  of  monomania. 


» 
THERAPEUTICS.  333 

and  many  unruly  dements  are  proper  subjects  for  a  lunatic  asylum;  and 
the  harmless  dement,  in  the  early  stage  of  his  malady,  in  which  there  is 
often  some  graver  mischief  lurking,  finds  there,  at  the  earliest  possible 
period,  his  disease  correctly  diagnosed  and  properly  treated.  Secondary 
apathetic  and  paralytic  dementia,  on  the  other  hand,  are  fit  subjects  for 
treatment  in  private,  in  any  place  where  careful  attention  can  be  secured. 
The  determination,  when  removal  to  an  asylum  is  really  indicated,  is 
only  occasionally  difficult  in  melancholia:  what  we  observed  with  regard 
to  the  adoption  of  this  measure  in  hypochondriasis,  inclines  us  to  look 
upon  it  rather  unfavorably  than  otherwise  at  first  sight;  there  we  saw 
that  not  till  the  patient  has  become  wholly  incapable  of  self-control  does 
this  step  appear  to  be  at  all  called  for.  So,  likewise,  simple  melancholia 
does  not,  during  the  first  few  weeks,  seem  to  necessitate  removal  to  an 
asylum,  so  long  as  it  remains  of  a  mild  character  and  with  a  slight  dispo- 
sition towards  improvement;  probably,  change  of  scene  or  an  excursion 
to  the  country  may  prove  sufficient,  provided  that  the  patient  is  there 
surrounded  by  judicious  attendants  who  Avill  studiously  enforce  all  the 
directions  of  the  physician.  But,  on  the  other  hand,  if  the  melancholia 
has  continued  for  some  months  unchanged,  and  rather  increasing  than 
otherwise;  and  if  the  patient  become  from  time  to  time  subject  to  illu- 
'sions,  and  becomes  disturbed  by  troublesome  hallucinations;  or  if  the  case 
degenerates  into  one  of  hopeless  stupidity  or  apathetic  indifference — re- 
moval to  an  as3"lum  must  no  longer  be  delayed.  However,  tlie  indication 
depends,  in  many  cases,  less  upon  the  form  and  kind  of  the  disease  than 
ufton  the  circumstances  and  character  of  the  patient.  It  is  always  the 
more  necessary  according  as  it  is  less  possible  for  the  patient  to  have  paid 
him  at  home  all  the  attention  he  needs;  for  the  less  2)erfectly  the  measures 
necessary  for  treatment  can  be  carried  out,  the  more  does  the  patient 
seem  disposed  resolutely  to  resist  them. 

The  prejudice  that  the  reason  of  the  patient  will  only  become  more 
deeply  affected  by  intercouse  with  other  lunatics,  springs  from  the  gross- 
est ignorance  of  the  subject.  In  every  well-ordered  institution  there  is 
a  proper  separation  of  the  inmates,  so  that  each  individual  associates  only 
with  a  few  whose  company  is  suitable;  the  new  patient  never  has,  for 
example,  any  intercourse  with  the  bad  and  liopeless  cases,  which  could 
not  fail  to  exercise  a  deleterious  influence  upon  him.  Those  patients 
who  come  in  contact  with  one  another,  though  on  the  best  of  terms,  are 
at  the  same  time  profoundly  indifferent  about  each  other,  each  one  being 
almost  wholly  occupied  with  himself.  Many  remark  the  insanity  of 
others,  and  become  cognizant  of  their  own  state  by  observing  that  a  simi- 
lar course  of  treatment  is  adopted  towards  them;  and  it  exerts  the  most 
beneficial  influence  upon  the  new  patients,  to  be  led  spontaneously, 
through  the  example  of  those  around  them,  to  conform  to  the  order  and 
routine  of  the  establishment,  and  to  learn  from  the  others  submission  to  all 
over  them,  and,  from  the  recoveries  and  dismissals  taking  place  around 
them,  to  become  tranquil,  and  encourage  the  hope  that  they  too  will  some 
day  be  dismissed. 

SECTiOif  II. — Physical  Treatment. 

§  211.  The  reflection  that  many  of  these  patients  recover  spontane- 
ousiv  under  a  system  of  treatment  in  favor  of  which  nothing  more  can 
be  said  than  that  it  is  not  positively  injurious,  will  guard  us  against  vul- 
gar therapeutic  illusions.  The  idea  of  some  specific  against  insanity  as 
a  whole,  or  against  its  various  forms,  mania,  melancholy,  etc.,  is  coun- 


334  THEKAPEUTICS. 

terbalanced  by  the  reflection  how  widely  different  the  diseases  which  give 
rise  to  the  symptoms  of  insanity  are  in  relation  to  the  anatomical  state  of 
the  brain  and  to  the  pathogeny.  The  primary  object  of  somatic  treatment 
is  the  progressing  morbid  state  which  led  to  the  development  of  the  cere- 
bral disease,  with  special  regard  to  the  organs  of  circulation  and  respira- 
tion; to  the  condition  of  the  blood,  of  the  secretions,  of  the  gastro-intes- 
tinal  mucous  membrane,  and  to  the  organs  of  generation.  The  treatment 
of  the  anomalies  here  observed  presents  no  peculiarity.  The  admission 
of  such  disorders  without  sufficient  foundation,  but  only  suggested  by 
theoretical  supposition  to  strengthen  a  particular  hypothesis,  must,  on 
the  one  hand,  be  carefully  guarded  against.  On  the  other  hand,  it  is 
to  be  remembered  that  in  insanity  the  diagnosis  of  bodily  disease  is  often 
rendered  very  difficult,  inasmuch  as  many  patients  do  not  at  all,  or  very 
inadequately,  express  their  sensations;  and  because,  in  virtue  of  the  brain 
affection,  many  symptoms — especially  subjective — which  we  otherwise  find 
are  absent,  as  in  phthisis,  pneumonia.  Therefore  ought  the  objective  diag- 
nosis to  be  more  carefully  practised.  Where  no  rational  indications  in  a 
pathogenetic  point  of  view  present  tiiemselves,  the  present  state  of  the 
brain  is  exclusively  the  object  of  somatic  treatment;  and  according  to  the 
Drobability  or  certainty  of  cerebral  irritation — hyperaemia — or  inflamma- 
tion, the  treatment  ought  to  be  immediately  directed  against  these  con- 
iitions  precisely  as  under  other  circumstances. 

In  the  use  of  medicines,  the  prevalent  opinion  that  the  insane  always 
require  considerably  larger  doses  is  frequently  hurtful  to  the  patient.  In 
many  cases,  no  ground  for  this  opinion  exists;  in  others,  the  greater  toler- 
ance is  only  apparent,  since  the  patient  conceals  many  adverse  effects,  as 
nausea,  in  the  storm  of  the  delirium  they  are  not  observed,  or  by  a  peculiar- 
ity of  his  disease  the  patient  endures  them  without  complaint,  wliile  the 
action  upon  the  organs  in  no  case  fails;  for  example,  erosion  of  the  gas- 
tric mucous  membrane  by  large  doses  of  tartar -emetic:  only  in  a  few 
cases  are  uncommonly  large  doses  of  certain  medicines,  particularly  pur- 
gatives and  narcotics,  given.  In  this  respect  there  is  great  difference 
among  individuals,  and  the  effect  cannot  be  reckoned  beforehand;  there- 
fore moderate  doses  must  in  all  cases  be  first  tried,  from  which  (of  course, 
sometimes  rapidly)  a  transition  to  stronger  ones  may  be  made. 

In  general,  special  somatic  treatment  is  more  needful  in  recent  than  in  long- 
protracted  states  of  insanity.  These  latter  cases,  where  so  frequently  the  bodily 
health  is  not  disturbed,  give,  therefore,  no  decided  indications  for  the  use  of  medi- 
cines, nor  has  their  empirical  employment  by  way  of  trial  shown  itself  in  the 
least  degree  beneficial.  Still,  there  are  cases  where,  even  without  rational  indi- 
cation, it  is  advantageous  to  give  medicines  to  the  patient,  but  consisting  only  of 
indifferent  substances,  merely  to  show  him  that  he  is  really  considered  ill,  to  sus- 
tain hope,  and  to  remind  him  of  a  steady  medical  supervision.  Here  medicines 
act  as  moral  remedies,  as  in  the  case  of  very  distrustful  patients  who  look  upon 
the  asylum  as  a  state  prison,  a  place  for  criminals  and  the  like — of  hypochondri- 
acs, etc.  Under  the  subject  of  bodily  treatment  we  shall  not  speak  of  all  the 
means  which  might  be  indicated,  but  only  of  those  which,  with  direct  reference 
to  the  brain-disease,  show  themselves  to  be  decidedly  useful,  or  such  as  from  the 
nature  of  the  symptoms  would  be  specially  indicated. 

§  212.  The  use  of  bleeding,  to  which  physicians  have  been  led  partly 
and  principally  by  theories  of  inflammation,  partly  by  the  results  of  path- 
ological anatomy — partly  by  the  symptoms  of  the  diseases,  which  are 
often  violent — has  in  recent  times  been  considerably  restricted,  and  all 
are  agreed  that  the  necessity  for  venesection  is  not  to  be  inferred  from 
delirium,  or  any  of  its  forms,  even  the  most  active,  excited,  and  furious. 


THERAPEUTICS.  335 

A  state  of  generally  diminished  nutrition  and  anaemia,  not  only  after 
loss  of  blood  and  other  causes  of  physical  weakness,  but  quite  as  frequently 
after  prolonged  states  of  mental  pain,  belong  very  often  to  the  etiological 
conditions  of  insanity,  and  especially  of  mania.  These  cases,  and  next  to 
them  such  as  arise  from  habitual  intemperance,  naturally  contra-indicate 
any  abstraction  of  blood. 

If,  however,  bleeding  be  employed  in  such  cases,  there  usually  follows 
an  aggravation  of  all  the  symptoms:  its  practice,  therefore,  in  individuals 
hitherto  melancholy,  very  frequently  causes  an  outbreak  of  mania.  In 
the  states  of  extreme  excitement  which  accompany  acute  meningitis,  and 
in  decided  general  plethora,  it  is  more  justifiable;  but  even  here  venesec- 
tion is  generally  quite  superfluous:  decided  and  rapid  results  are  specially 
seen  only  in  those  sudden  and  violent  states  of  congestion  which  some- 
times appear  along  with  the  symptoms  of  mental  disorders  after  strong 
sudden  emotions,  with  stormy,  irregular  heart-action,  and  symptoms  of 
overfulness  of  the  lesser  circulation. 

Venesection  was  formerly  the  subject  of  various  opinions  and  numerous  dis- 
cussions;' the  conviction  is  now  general  that  in  most  cases  it  is  not  only  useless, 
but  injurious,  and  that  seldom  it  is  of  real  utility;  and  we  cannot  too  earnestly 
exhort  those  practitioners  whose  chief  care  is  devoted  to  the  insane,  as  far  as  pos- 
sible to  spare  the  blood  of  their  patients.  Formerly,  in  Bethlehem  all  the  patients 
were  bled  several  times  during  the  summer;  and  the  most  abused,  most  extensive, 
use  of  this  remedy  was  known  in  France  during  the  last  century  as  ' '  traitement 
de  I'Hotel-Dieu."  Willis,  Chiarugi,  but  especially  Pinel,  declared  themselves 
strongly  against  the  abusive  use  of  bleeding;  Hill,  Esquirol,  Burrows,  and  most 
of  the  German  physicians,  agreed  with  them.  The  chief  advocate  of  profuse 
bleeding,  especially  in  mania,  was  Rush  ('  Untersuchungen  iiber  die  Seelen-Krank- 
heiten,'  translation  by  Konig,  Leipzig,  1825,  p.  149);  Haslam,  Foville,  and  others, 
frequently  employed  it  in  a  moderate  degree.  It  is  remarkable  that  out  of  206 
patients  upon  whom  Haslam  performed  venesection  in  Bethlehem,  the  blood  of  6 
only  showed  a  crust  (Rush,  1.  c,  p.  150).  Several  indications  for  venesection, 
which  are  only  partially  true,  have  been  laid  down,  such  as  youth,  recentness  of 
attack,  strong  pulsation  of  the  arteries  of  the  head — which,  however  is  also  pres- 
ent in  delirium  resulting  from  anaemia  (M.  Hall):  moderate  cerebral  congestion 
(warm  head,  redness  of  the  eyes,  etc.)  does  not  at  all  indicate  a  necessity  for  vene- 
section, as  it  is  frequently  the  result  of  impaired  genei'al  nutrition. 

Local  bleeding  by  means  of  cupping-glasses  and  leeches  is  much  more 
generally  employed  than  venesection.  In  acute  meningitis  its  effect  is 
more  certain  and  more  immediate  in  relieving  the  brain;  in  intense  cere- 
bral congestions  we  frequently  see  it  exercising  a  very  favorable  and  rapid 
influence  upon  the  mental  disease;  and  if  the  effect  is  seldom  permanent, 
the  remedy  can  easily  be  repeated:  sometimes  its  long-continued  application 
at  regular  intervals  is  attended  with  a  favorable  result.  Simple  hyperae- 
mias  alone  yield  to  these  means;  that  the  true  chronic  meningitic  and  en- 
cephalitic  processes  can  no  more  be  removed  through  bleeding  than  other 
chronic  inflammations,  will  not  suprise  us  if  we  consider  the  previous  pro- 
cesses which  there  take  place.  Cupping-glasses  should  be  applied  to  the 
shaven  scalp  or  to  the  nape  of  the  neck;  leeches  should,  where  possible,  be 
applied  in  the  neighborhood  of  emissaries — behind  the  ear,  to  the  Schnei- 
derian  membrane,  the  veins  of  which  communicate  with  the  longitudinal 
sinus,  etc.    In  women  it  may  be  sometimes  necessary  to  apply  the  leeches 

'  Resumes  of  this  subject  are  given  by  Friedreich,  in  Friedreich  and  Bluroder's 
'  Blatter  fiir  Psychiatrie;'  J.  Nasse,  in  Jacobi's  and  Nasse's  '  Zeitschrift,'  i.,  p.  216; 
Smith,  'On  the  Bad  Effects  of  General  Bloodletting,"  etc.,  '  Lancet,' August, 
1846;  Pliny  Earle,  '  American  Journal  of  Insanity,'  April  1852  (very  comprehen- 
sive). 


336  THERAPEUTICS. 

to  the  genital  organs;  abstraction  of  blood  from  the  anus  in  the  treatment 
of  congestion  of  the  head  is  an  uncertain  and  sometimes  even  prejudicial 
measure. 

§  213.*  In  the  treatment  of  hyperemia  of  the  brain,  cold  is  extensively 
and  advantageously  employed,  but  not  in  the  form  of  the  ordinary  cold 
plunge-baths,  to  wliich  the  practitioner  so  readily  recurs  to  quiet  recent 
cases  of  mania,  but  which  frequently  only  increase  the  fury  and  even 
augment  the  cerebral  congestion,  Zeller,  and  in  latter  times  Jacobi, 
have  decidedly  expressed  themselves  against  the  fruitlessness  of  this 
mode  of  treatment.  We  have  ourselves  seen  cases  where  the  douche  was 
several  times  employed,  and  always  followed  by  a  visible  aggravations  of 
the  symptoms:  it  is  only  in  cases  of  melancholic  stupor  that  it  may  oc- 
casionally be  employed  with  advantage.  The  strong  shower-bath  should 
scarcely  be  employed  as  a  means  of  cure,  but  rather  as  a  means  of  punish- 
ment auxiliary  to  moral  treatment;  to  this  end  it  should  only  be  contin- 
ued for  a  short  time,  and,  if  necessary,  repeated  during  the  day. 

Amongst  modern  authors  who  still  recommend  the  douche,  Ideler  may  be  es- 
pecially mentioned  (Charite-Annalen,  i.,  4,  1850,  p.  692).  Besides  he  applies  it 
more  frequently  to  the  spine  than  to  the  head  (from  the  neck  to  the  haunches); 
this  he  has  found  exceedingly  useful  in  idiopathic  insanity  (which,  accoi'ding  to 
him,  arises  immediately  from  the  passions!)  during  the  period  of  remission  in 
mania,  in  states  of  general  sluggishness  and  stupor,  in  certain  cases  in  melancholia 
and  monomania,  and  also  in  individuals  who  have  become  affected  through  alco- 
holic and  sexual  excesses. 

The  application  of  the  ice  to  the  head,  or  of  cold  compresses,  which 
the  patient  himself  often  earnestly  desires,  is  also  useful  in  many  states 
of  excitement  where  the  head  is  hot,  the  carotid  arteries  pulsate  strongly, 
etc. ;  and  the  application  of  cold  to  the  head  during  a  tepid  bath,  either 
in  the  form  of  a  compress  or  as  a  shower  gently  falling  from  a  moderate 
height,  is  particularly  beneficial.  The  great  calm  which  often  succeeds, 
and  the  marked  feeling  of  ease  experienced  by  the  patient,  may  indicate 
the  advantage  of  employing  it  even  several  times  a  day  to  allay  agitation 
as  often  as  it  appears.  Insolation,  wounds  of  the  head,  threatening 
apoplexy  Avith  symptoms  of  congestion,  render  the  application  of  cold  to 
the  head  especially  urgent. 

On  the  other  hand,  baths  of  the  most  varied  description  are  now 
much  more  extensively  employed,  and  their  judicious  use  is  followed  by 
the  greatest  advantage  in  the  disorders  of  the  brain  which  are  the  causes  of 
insanity.  Occasionally,  especially  in  young  persons  of  the  female  sex  and 
in  hysterical  patients,  the  use  of  cold  baths,  and  if  possible  of  river  baths, 
is  indicated:  of  more  general  employment  and  utility  are  tepid  baths  in 
older  and  especially  in  recent  cases.  Besides  their  cleansing  and  invigorat- 
ing effect,  they,  by  uniformly  and  gently  stimulating  the  nerves  of  the 
skin,  and  moderating  and  regulating  the  respiration  and  heart's  action, 
appear  to  exert  a  remarkably  tranquillizing  influence  in  these  diseases. 
They  are  usually  continued  for  from  thirty  minutes  to  one  hour;  in 
acute  cases  where  there  is  extreme  excitement  this  period  is  often  insuffi- 
cient, and  in  such  cases  the  plan  recommended  by  Brierre  de  Boismont, 
of  leaving  the  patient  in  the  bath  for  several  hours,  a  uniform  temper- 
ature of  course  being  maintained,  proves  a  very  valuable  means  of  treat- 
ment. This  method,  however,  is  not  suitable  in  chronic  conditions — in 
agedj  weakly  cachectic  persons,  when  the  pulse  is  weak — or  in  epilepsy 


THERAPEUTICS.  337 

and  commencing  pcaralysis. '  The  bath  frequently  induces  the  much-re- 
quired sleep.  It  often  seems  to  prevent  hyperaemia  of  the  brain  from  be- 
coming fixed;  and  where  the  patients  willingly  submit  to  the  remedy, 
there  is  scarce  any  contra-indication  to  its  use,  excepting  phthisis,  evi- 
dent ana3mia,  or  general  paralysis,  whether  incipient  or  confirmed.  Ac- 
cording to  circumstances,  sulphur,  iron,  aromatic  plants,  etc.,  may  be 
added.     Footh-baths,  in  certain  cases,  assist  in  relieving  the  head. 

In  the  first  edition  of  this  work,  I  have  already  expressed  my  opinion  of  the 
treatment  in  hydropathic  institutions.  Since  tlien,  facts  from  all  quarters  have 
been  elicited  proving  tlie  injury  which  it  generally  iniiicts  on  the  mentally  dis- 
eased. Most  asylum  physicians  are  in  a  position  to  contribute  examples  of  this: 
Flemming,  Erlenmeyer,  Damerow,  Sponholz,  etc.,  have  expressed  tliemselves 
decidedly  upon  this  point.  This  violent  procedure  seems  much  to  favor  the 
transition  to  general  ))aralysis.  The  absurdity  of  sending  i)atients  to  cold-water 
establishments,  instead  of  into  lunatic  asylums,  would  be  incredible  were  it  not 
of  daily  occurrence,  still,  it  is  evident  that,  in  certain  cases,  the  occasional  use  of 
wet  compresses,  cold  sitz-baths,  and,  above  all,  cold  washing  followed  by  dry 
friction,  can,  under  special  indications,  be  beneficially  employed.  Guislain  has 
laid  down  several  rather  indefinite  rules  for  the  administration  of  cold  baths 
(from  14-17  R.,  5-25  nnnutes;  'Leg.  or.,'  iii.,  p.  115):  he  has  found  them,  how- 
ever, of  more  general  service  in  cases  of  upwards  of  six  months'  standing,  than 
in  quite  recent  cases.  Jacobi's  practice  ('  Ztschr.  f.  Psych.,'  xi.,  p.  379)  of  quietmg 
maniacal  excitement  by  means  of  baths  of  half  an  hour's  continuance,  and  of  13° 
R. ,  appears  to  be  very  well  considei-ed. 

§  214.  The  cutaneous  irritants  and  the  so-called  derivatives  are  often 
applied  to  improper  parts.  Blisters  are,  in  ordinary  cases,  useless:  placed 
upon  the  head,  they  frequently  increase  the  irritation;  in  melancholic 
stupor,  again,  they  seem  occasionally  to  be  used  with  advantage,  espe- 
cially when  placed  upon  the  neck.  The  ointments  and  plasters  of  tartar- 
emetic,  which  are  used  by  some  in  the  most  extravagant  manner,  even  to 
necrosis  of  tlio  cranial  bones,  arc  certainly  useful,  especially  in  certain 
melancholic  forms,  and  occasionally  in  protracted  transitions  of  the 
primary  forms  into  states  of  weakness  (Jacobi).  These  also  are  applied 
to  the  skull,  to  the  neck,  and  even  to  more  distant  parts,  and  should 
only  be  continued  till  moderate  suppuration  ensues;  they  are  chiefiy  use- 
ful in  a  moral  aspect,  as  the  continued  acute  pain,  which  constantly 
forces  itself  on  the  consciousnees,  breaks  the  chain  of  morbid  ideas,  and 
prevents  tlie  mind  dwelling  on  them.  The  seton  might  be  advanta- 
geously employed,  especially  in  certain  cases  of  injury  to  Ihe  head.  The 
moxa  and  cautery,  the  latter  of  which  was  often  ineffectually  employed 
in  former  times  in  general  paralysis,  do  not  possess  any  permanent  ad- 
vantage, and  are  not  now  used.  All  these  grave  cutaneous  irritants  are  not 
only  quite  unserviceable  in  cases  of  acute  excitement,  but  also  in  cases  of 
deep  dementia,  where  the  irritated  surface  is  often  subjected  to  violent 
rubbing  and  to  the  action  of  cold:  serious  erysipelatous  inflammations 
may  hereby  result,  and  in  certain  powerless  conditions  gangrene  may 
even  ensue — dangers  which  are  far  from  being  counterbalanced  by  the 
problematic  advantages  of  these  applications. 

Tartar-emetic  ointment  had  gone  much  out  of  use,  when  the  account  of  some 
happy  results  gained  by  Jacobi  again  brought  it  for  a  time  into  favor.  This 
author  had  a  part  of  the  top  of  the  head  shaved,  upon  which  he  painted  some  of 


'  See  Brierre,  'Mem.  de  I'Acad.  de  Med.,'  1847.  He  allowed  maniacs  to  remain 
in  a  warm  bath,  sometimes  for  from  six  to  ten  hours,  with  cold  applied  to  the 
head;  but  from  three  to  four  hours  will  always  be  found  sufficient.  Pinel's  nephew 
has  given,  in  cases  of  mania,  baths  of  several  days'  (!!)  continuance,  with  a  con- 
stant stream  of  cold  water  on  the  head. 
23 


338  THERAFEUTICS. 

the  ointment  with  a  brush  until  the  inflammation  and  swelling  spread  over  all 
the  head,  and  the  skin  upon  the  place  of  application  sloughed  and  was  brought 
away  with  poultices  ( !) :  during  this  time  the  patient  was  allowed  only  water, 
soup,  milk,  and  white  bread.  Several  chronic  cases,  in  the  stage  of  transition  to 
clironic  mania  and  dementia,  were  improved  by  this  treatment;  Guislain  and 
others  obtained  some  good  results  from  it  in  the  same  states,  and  also  in  melan- 
choly with  stupor,  and  other  similar  conditions.  The  employment  of  such  means, 
which  should  only  be  used  in  desperate  cases,  is,  under  all  circumstances,  wholly 
to  be  avoided  in  mania,  in  recent  cases  with  great  excitement,  and  in  very  sensi- 
tive irritable  natures  already  exhausted  by  bodily  or  mental  pain. 

§  215.  At  first  sight,  mucli  might  be  expected  from  the  direct  influ- 
ence of  narcotics  upon  the  functions  of  the  brain.  The  cases,  however, 
in  which  these  remedies  can  be  advantageously  employed  will  be  much 
reduced  if  we  consider  how  frequently  insanity  is  the  gradually  matured 
and  deep-rooted  result  of  combined  influences,  that  it  often  depends 
upon  anatomical  changes,  and  that  even  the  most  powerful  narcotics, 
with  some  notable  exceptions,  are  suited  rather  for  temporary  use. 
Observation  also  shows  that  these  remedies  are  only  serviceable  within  a 
limited  circle  of  conditions,  in  which  they  are  certainly  very  useful  as 
means  of  cure,  and,  besides,  they  are  of  essential  service  in  diminishing 
and  suppressing  certain  symptoms. 

Among  all  remedies  of  this  kind,  opium  is  pre-eminent  for  its 
narcotic  effects,  and  also  as  that  from  which  in  other  respects  we  can 
anticipate  the  most  powerful  results;  not,  however,  as  it  was  formerly 
used,  in  small  and  squandered  doses,  which  had  little  or  no  permanent 
effeftt,  but  in  doses  larger  and  longer  continued— a  method  which  must 
be  admitted  to  be  in  advance  of  modern  psychiatry.  According  to  this 
method,  there  is  given  at  first  about  one  grain  twice  a  day;  this  is  grad- 
ually increased  to  3-6  grains  twice  a  day,  which  is  continued  for  several 
weeks.  By  this  system,  no  appearances  of  intoxication  are  observed, 
and  no  unfavorable  influence  on  the  nutrition;  regular,  indeed  rather 
loose  stools,  where  we  employ  larger  doses;  there  is  never  profuse  sleep, 
but,  in  cases  adapted  for  this  treatment,  rather  improvement  in  the 
symptoms  of  cerebral  irritation,  increasing  quietness  of  the  patients, 
lessening  of  the  hallucinations,  disappearance  of  the  feelings  of  anxiety 
and  of  the  insane  notions  accompanying  them,  and  sometimes  rapid  and 
complete  recovery.  It  is  in  harmony  with  numerous  and  concurring 
experiences,  that  in  recent  cases,  in  young  persons,  and  especially  in 
women,  in  states  of  sadness  due  to  the  influence  of  anasmia,  hypo- 
chondriasis, hysteria,  and  mental  causes  often  advancing  to  great  dis- 
quietude and  excitement  (active  melancholy),  such  favorable  influences 
should  make  their  appearance,  particularly  also  in  many  puerperal 
mental  disorders,  and  in  deliritim  tremens.  In  the  conditions  of  melan- 
choly with  stupor,  and,  above  all,  with  great  passiveness;  in  mania 
proper,  in  the  lively  excitement  of  monomania — this  method  seems  to 
effect  nothing:  it  follows,  therefore,  that  the  cases  for  its  use  occur  more 
frequently  in  private  practice,  during  a  short  existence  of  the  malady, 
than  in  asylums. 

SeeH  Engelken,  '  Prot.  der  Naturforscher-Versammlung  in  Bremen,  1844;' 
F  Engelken,  '  Zeitschrift  fiir  Psychiatric,'  viii.,  1851,  p.  393;  Schubert,  'Med. 
Vereinszeitung,'  1857,  No.  24;  L.  Meyer,  '  Ztschr.  f.  Psych.,'  1860,  No.  4;  Erlen- 
meyer,  '  Arch.  d.  d.  Ges.  f.  Psych.,'  iii.,  1, 1860,  p.  53.  Besides,  many  physicians, 
Guislain  (' Leo.  or.,'  iii.,  p.  28),  Michea,  ZeUer,  etc.,  have  expressed  theniselves 
favorably  upon  the  system  of  large  doses.  Morphia  appears  to  be  less  serviceable 
than  opium;  Guislain  alone  ascribes  to  it  better  effects. 

Likewise  in  states  of  excitement,  but  especially  of  a  maniacal  kind. 


THERAPEUTICS.  339 

« 

digitalis  is  employed.  Although  it  is  primarily  indicated  by  irregularity 
of  the  circulation,  yiolent  heart's  action,  great  frequency  of  pulse,  and 
by  changes  of  structure  in  the  heart — and  then  it  may  be  employed  in 
melancholia  as  well  as  in  mania — nevertheless  the  empirical  use  of  this 
medicine  is  often  Justified  by  its  success,  even  in  cases  where  there  is  no 
disturbance  of  the  cardiac  etficiency.  Digitalis  has  the  advantage  that  it 
can  1)6  given  for  a  long  time  continuously,  and  may  in  certain  cases  be 
advantageously  combined  with  other  diuretics;  moderate  doseS  are  at 
first  employed;  the  acceleration  of  the  pulse  occasionally  observed  during 
the  early  periods  of  its  use  passes  speedily  into  abatement,  and  in  certain 
cases  it  is  advantageous  to  keep  the  pulse  for  some  time  under  the 
normal  frequency  by  doses  of  the  medicine  adapted  to  each  case;  the 
larger  doses,  which  easily  produce  vomiting,  should  be  only  carefully 
and  gradually  administered.  States  of  sexual  excitement  contra-indicate 
the  use  of  digitalis,  which,  like  other  diuretics,  appears  to  increase  the 
excitement,  and  sometimes  is  what  first  calls  it  forth. 

High  expectations  were  formed  of  ether  and  chloroform  when 
ansesthesia  was  first  discovered;  and  certainly  complete  and  raj)id  recov- 
ery has  occurred  in  several  cases  of  recent  active  melancholia.  But 
numerous  observations  have  shown  that  frequently  (although  not  in- 
variably) a  temjiorary  remission  of  the  melancholia  and  mania,  some- 
times a  complete  lucid  interval,  follows  the  awaking  from  the  narcotic 
effects  of  chloroform;  soon  afterwards,  however,  the  morbid  symptoms 
return,  and  with  each  inhalation  the  remissions  gradually  shorten  till 
they  can  no  longer  be  obtained.  Certainly,  there  are  cases,  as  in  violent 
puerperal  mania,  where  it  is  of  the  utmost  importance  to  obtain  a  short 
interval  of  calm,  and  in  such  cases  angesthesia  may  be  employed:  ether 
clysters  (3j.  to  3  j.)  may  also  be  used  to  obtain  quiet  m  states  of  nervous 
excitement.  But  often  it  does  not  exert  this  soothing  effect,  sometimes 
it  seems  rather  to  increase  the  agitation.  In  all  cases  the  utmost  care 
should  be  observed  in  its  administration  (proper  entrance  of  air,  etc.). 

See  Meyer,  '  Charite  Annalen,'  viii.,  2,  1857,  p.  69.  Morel  (1854)  employed 
ansesthesia  to  discover  malingering,  but  without  effect. 

Hydrocyanic  acid  (Aqua  Lauro-cerasi,  Aqua  Amygdal.  Amar.)  is 
occasionally  useful  as  an  accessory  medicine  in  states  of  moderate  exalta- 
tion, melancholic  anxiety,  etc.,  in  the  early  stages.  Its  sedative  effect 
appears  to  us  to  be  more  effectual  in  females.  The  use  of  Datura 
Stramonium,  which  was  long  ago  much  employed,  has  been  recently 
revived  with  some  success,  especially  in  hallucinations  of  sight,  hearing 
(Moreau,  Billod).  In  the  hallucinations  of  chronic  mania  and  dementia 
it  has  no  effect,  and  numerous  proofs  of  its  uselessness  in  other  cases  may 
be  found.  Nevertheless,  it  appears  to  be  beneficial  in  cases  wliero  si- 
multaneously with  the  outbreak  of  insanity  the  hallucinations  of  hearing, 
which  on  account  of  their  immediate  psychical  effects  are  so  unfavorable, 
constitute  the  chief  symptoms.  It  must  then  be  administered  in  large, 
even  intoxicating,  doses.'  Belladonna,  which  is  now  little  used,  can 
also  be  tried  in  predominant  hallucinations  of  the  above  two  senses. 
There  are  no  established  indications  for  the  employment  of  these 
remedies,  both  of  them  seem  contra-indicated  when  there  is  hyperaemia 

'  But  with  great  caution:  we  have  seen,  in  a  case  in  the  Salpetriere,  consider- 
able emaciation,  a  state  of  marasmus,  result.  More  recent  experiences,  which 
may  be  of  some  eflacacy  in  hallucinations,  by  Boureau,  may  be  found  in  the 
'Annales  Med.  Psychol.,'  vi.,  1854,  p.  555. 


34:0  THERAPEUTICS, 

of  the  brain.  Quinine  is  useful  in  regularly  intermitting  forms,  and  can 
also  be  advantageously  used  to  counteract  certain  neuralgic  states  which 
are  often  evidently  productive  of  delirious  ideas.  Assafoetida  has  been 
recommended  by  Gruislain  in  large  doses,  in  hysterical  affections  of  the 
mind.  Certain  medicines  (Brucin,  Hachish,  etc.),  which  hitherto 
have  been  little  used,  promise  by  careful  experiment  to  become  valuable 
adjuncts  to  mental  therapeutics. 

Alcoholics  are  to  be  wholly  condemned  in  the  treatment  of  the  insane 
in  general,  particularly  in  recent  cases;  during  convalescence,  they  are 
only  to  be  administered  with  the  utmost  caution.  It  is  only  in  ex- 
ceptional cases,  as  in  those  of  former  drunkards  who  have  fallen  into  a 
state  of  deep  mental  weakness  with  serous  infiltration  of  the  extremities, 
that  the  use  of  strong  wine  may  be  useful. 

Tobacco  is  much  used  by  the  insane,  but  only  in  snuffing  and  smoking.  The 
great  predilection  of  many,  especially  chronic  patients,  for  the  irritation  of  snuff 
is  well  known;  and  often  a  snuff  good-humoredly  offered  to  an  insane  person 
prevents  him  breaking  out  in  a  storm  of  invectives,  brings  him  to  himself  and 
calms  him.  Strong  snuff  is  occasionally  administered  to  produce  a  sanguineous 
secretion  from  the  Schneiderian  membrane.  The  smoking  of  tobacco  by  those 
who  have  been  accustomed  to  it,  aids  the  easy  flow  of  the  ideas  and  equalizes  the 
temper.  The  return  of  the  desire  should  be  Avatched  and  encouraged;  for  even 
such  habits,  unimportant  in  themselves,  may  assist  the  mind  to  resume  its 
former  thoughts,  and  to  follow  its  former  courses.  In  the  commencement  of 
paralysis,  all  use  of  tobacco  should  be  forbidden. 

§  216.  Those  medicines  which  act  upon  the  digestive  canal  are  the 
oldest,  and  still  those  that  are  most  frequently  used.  Besides  their 
evident  indication  in  constipation — which  is  common  in  these  diseases, 
and  very  often  better  obviated  by  dietetic  means  and  mild  clysters  than 
by  medicines — they  are  also  given  with  advantage  in  all  recent  cases  asso- 
ciated with  cerebral  congestion,  and  are  the  chief  remedy  in  acute 
inflammatory  states  of  the  brain.  Strong  and  rapid  purgatives  (croton 
oil,  etc.)  are  suitable  in  these  cases;  for  a  more  moderate  effect,  senna, 
rhubarb,  and  the  various  saline  purgatives,  are  used.  The  long-con- 
tinued employment  of  mild  laxatives  (the  various  salts  of  potash  and 
soda,  or,  better  still,  the  aperient  soda  mineral  waters)  often  proves 
useful  in  chronic  cases,  even  where  there  is  no  constipation.  We  must 
not  expect  from  the  use  of  these  means  a  great  curative  action,  and  in 
hypochondriacal  state  they  often  prove  injurious.  Drastic  cathartics  are 
to  be  entirely  avoided  where  there  is  chronic  disease  of  the  genital 
organs,  and  the  long-continued  use  of  any  strong  purgative  may  become 
the  cause  of  serious  intestinal  catarrh. 

Emetics  are  sometimes  employed  in  the  treatment  of  evident  disorder 
of  the  gastric  digestion;  occasionally,  especially  in  melancholia,  they  are 
employed  chiefly  for  their  mental  effects;  in  puerperal  mental  disorders 
especially,  a  rapid  and  favorable  effect  is  sometimes  observed  (Flemming). 
The  so-called  nauseant  cure  by  small  doses  of  tartar-emetic  may,  per- 
haps, through  its  long-continued  nauseous  impression  upon  the  nervous 
system,  modify  the  humor  and  interrupt  the  mental  pain  by  substitution 
of  a  disagreeable  bodily  sensation.  In  the  same  way,  the  maniac  may  be 
quieted  by  the  prostration  which  is  consequent  on  the  medicine;  but  any 
real  advantage  is  but  seldom  obtained:  while  there  are  no  decided 
reasons  for  the  continuance  of  these  palliative  means,  their  injurious 
effects  are,  on  the  other  hand,  evident.  The  whole  system  of  the  nauseant 
cure  is  to  be  considered  a  remnant  of  the  barbarous  age  of  therapeutics, 
and  the  enormous  doses  of  tartar-emetic  (gr.  xij.-xx.)  Avhich  are  em- 


THERAPEUTIUo.  \  341 

ployed  by  some  are  to  be  emphutically  denounced.  The  consequences  of 
such  rough  j)]actice  are  not  only  the  formation  of  pustules  in  the  mouth 
and  oesopliagus,  circumscribed  gastritis,  but  rapid  paralytic  collapse  may 
even  result.  Anthelmintics  are  occasionally  useful,  especially  in  the 
mental  disorders  of  children. 

§  217.  Of  the  class  of  excitants  which  have  a  special  action  on  the 
nervous  system,  camphor  has  for  a  long  time  been  much  employed.' 
The  experiences  of  several  practitioners  warrant  us  in  making  further 
trial  of  this  remedy.  It  is  especially  indicated  in  cases  of  sexual  irrita- 
tion, as  seen  at  the  outbreak  of  puerperal  insanity;  in  such  cases  it  must 
be  administered  in  considerable  doses.  The  experiments  with  musk, 
phosphorus,  arnica,  etc.,  to  "vivify"  the  brain,  betray,  in  our  oioinion, 
an  uncommon  degree  of  ignorance  of  therapeutics. 

Cooling  remedies  are  frequently  indicated — as  nitre,  acid  drinks,  etc. 
Bitters  and  tonics  may  bo  necessary  in  cases  of  long-disordered  digestion 
and  in  anaemia.  Iron  is  especially  useful  in  many  cases,  and  is  very 
beneficial  in  many  nervous  hysterical  disorders  of  females;  cod-liver  oil 
may  be  advantageously  administered  with  it  in  cases  of  angemia  with 
emaciation.  Emmenagogues  are  frequently  useful,  particularly  at  the 
commencement  of  insanity,  partly  arising  from  disorders  of  tlie  menstrual 
functions:  in  chronic  cases,  also,  menstruation  is  to  be  Avatched.  More 
frequently,  however,  it  is  necessary  to  apply  local  treatment  to  the  gene- 
rative organs,  as  in  uterine  catarrh,  aifections  of  the  vagina,  etc.,  so 
frequently  the  cause  of  functional  disorders  of  nerve-centres,  and  so  diffi- 
cult to  cure  by  internal  treatment.  Cases  frequently  occur  where  anti- 
sphilitic  treatment  is  necessary  to  counteract  cerebral  disease  (p.  138). 
The  emioloyment  of  electricity  without  evident  reasons  for  it  is  to  be  de- 
nofincect;  local  nervous  pains  may  occasionally  by  this  means  l^e  success- 
fully treated. 

§  218.  With  reference  to  diet  and  nourishment,  the  fact  that  insanity 
often  depends  upon  inflammatory  processes  within  the  cranium,  might 
suggest  the  necessity  of  antiphlogistic  regimen.  Notliing  would  be  more 
hurtful  to  the  patient;  experience  shows  that  these  diseases,  whether  de- 
pending on  such  inflammatory  processes  or  on  simple  irritation,  are  fre- 
quently associated  with  general  anaemia  and  defective  nutrition;  that 
frequently  the  appetite  of  the  patient  isincreased;  that  spare  diet  irritates 
and  is  positively  injurious;  that  tlie  frequent  increased  expenditure  of 
muscular  force  demands  correspondingly  increased  nourishment;  that 
the  general  state  of  the  patient  is  most  improved  by  stimulating  diet,  and 
that  refreshing  sleep,  and  the  feeling  of  well-being,  are  induced  by  suffi- 
cient food.  Of  course,  the  effects  must  be  carefully  watched,  and  the 
diet  regulated  accordingly;  in  acute  meningitis,  and  in  all  febrile  states, 
spare  diet  is  prescribed;  in  impaired  digestion,  simple  diet,  as  niilk,  etc., 
with  those  who  have  led  a  life  of  dissipation,  retirement,  and  simplicity, 
are  often  speedily  beneficial.  Water  and  simple  beverages  must  gene- 
rally be  the  drinks  allowed  (p.  348),  and  should  be  copiously  administered 
in  all  recent  and  acute  cases:  tea  and  coffee  are  forbidden  in  all  acute 
cases.  A  common  table  in  the  asylum,  where  admissible,  stimulates  the 
appetite  and  social  feeling  amonglhc  patients,  recalling  to  the  memory 
of  the  convalescent  those  customs  of  society  which  are  the  external  evi- 
dences of  healthy  sensations,  and  which  they  have  in  many  cases  forgot- 
ten. 


1  As,  for  example,  Perfect,  '  Selected  Cases,  etc.,  from  Michaelis,'   Leipzig, 

J  789 


342  THEKAPEUTICS. 

In  all  cases  of  insanity,  whether  recent  or  of  long  standing,  next  to- 
diet,  the  proper  regulation  of  rest  and  activity  is  most  necessary  to  be  ob- 
served, fresh  and  open  air,  and,  in  the  less  acute  cases,  abundance  of  out- 
door exercise  on  foot,  or  sometimes  in  a  carriage.  No  asylum  is  complete 
which  has  not  space  sufficient  to  admit  of  prolonged  outdoor  exercise  for 
all  classes  of  its  inmates — in  gardens,  airing-courts,  etc.  In  many  chronic 
cases  it  is  highly  beneficial  to  prescribe  gymnastic  exercises  and  cheerful 
games  which  necessitate  exercise,  where,  in  the  harmless  excitement  of  the 
game,  the  patient  for  a  time  forgets  self  and  the  thoughts  which  harass 
him.  Sleep  should  be  the  result  of  work,  of  exercise  in  the  open  air,  of 
fatigue;  it  may  also  be  promoted  by  baths,  by  quiet  and  stillness,  seldom 
by  narcotics.  Except  where  special  rest  is  necessary,  the  patient  should 
be  accustomed  to  early  rising;  idle  lying  in  bed,  which,  especially  with 
women,  so  easily  becomes  a  habit,  and  leads  to  considerable  enfeeblement 
of  the  whole  muscular  system,  should  not  be  allowed.  It  is  only  in  cer- 
tain cases  of  acute  melancholy,  where  there  is  a  general  enfeeblement  of 
the  vital  powers,  that  long  rest  in  bed  is  beneficial  and  necessary. 

As  to  temperature,  we  need  only  repeat  that  the  insane  are  not,  as 
was  formerly  supposed,  insensible  to  warmth  and  cold.  In  winter  the 
apartments  should  be  heated,  and  patients  who  are  inclined  always  to  sit 
still  or  stand  motionless,  and  whose  extremities  are  often  cold,  should  be 
the  objects  of  special  care.  Where  there  is  tendency  to  cerebral  conges- 
tion the  temperature  should  be  kept  low  and  the  head  cool. 

Personal  cleanliness  is  most  important.  The  methods  of  attaining^ 
this  are  well  known,  and  its  object  is  not  only  to  maintain  the  health  and 
function  of  the  skin,  to  prevent  the  evil  effects  of  prolonged  decubitus  in 
paralytics,  etc.,  but  the  feeling  of  comfort  which  corresponds  to  external 
attention  to  the  body  is  the  foundation  of  mental  well-being;  and  the 
habit  of  external  care  also  promotes  internal  order  and  regukirity.  In 
the  same  way  all  dietetic  measures,  when  systematically  employed,  act 
beneficially  on  the  patient.  They  are  therefore  a  powerful  aid  to  moral 
treatment,  while  all  outward  disorder  and  confusion  distract  the  mind,, 
and  thus  dem-ive  it  of  self-adjusting  power. 

Sectiok  III. — Moral  Treatment. 

§  219.  Mental  activity,  constantly  employed  on  account  of  its  indirect 
action  on  the  organic  processes,  is  also  used  to  call  up  ideas,  images,  feel- 
ings, and  efforts,  for  the  purpose  of  directly  modifying  mental  anomalies. 
This  is  effected  only  to  a  slight  extent  by  any  positive  influence  exerted  by 
the  physician  upon  the  patient,  such  as  exhortation,  encouragement,  or 
even  surprises,  punishments,  looks,  etc.;  much  is  gained  by  negative 
measures.  Often  even  the  gait  of  the  patient  is  such  as  to  admit  the 
hope  of  a  rapid  spontaneous  cure;  in  such  a  case  the  removal  of  all  ex- 
citing causes,  and  a  proper  regulation  of  the  external  circumstances,  are- 
frequently  sufficient,  especially  if  the  patient  has  also  the  feeling  of  sub- 
jection to  a  rational  and  well-meant  control,  and  is  being  gradually  habi- 
tuated to  proper  outward  behavior. 

The  more  direct  moral  action,  for  the  purpose  of  restoring  mental 
health,  may  again  be  reduced  to  two  indications,  which  may  be  under- 
stood quite  as  well  from  a  profound  theoretical  acquaintance  with  insanity, 
as  from  the  practical  knowledge  of  a  successful  system  of  treatment.  In 
the  first  place,  the  morbid  disi)ositions  and  ideas  which  repress  and  con- 
ceal the  former  (healthy)  individuality  must  be  uprooted  and  destroyed; 


THERAPEUTICS.  343 

in  the  second  place,  the  old  ego,  which  in  insanity  for  a  long  time  is  not 
lost,  but  only  superficially  repressed,  or  hidden  in  a  storm  of  emotion, 
behind  which  it  remains  for  a  long  time  capable  and  ready  to  re-establish 
itself,  must,  as  far  as  possible,  be  recalled  and  strengthened.     If,  as  Ave 
have  already  hinted,  there  is  some  analogy  between  tlie  moral  treatment 
of  the  insane  and  the  art  of  education,  in  the  aim  proposed  and  the  means 
employed,  they  present,  however,  essential  differences  in  the  latter  respect. 
For  in  the  moral  treatment  of  the  insane  the  creation  of  new  ideas  is  not 
contemplated,  but  the  re-establishment  of  the  old;  it  does  not  contem- 
plate any  improvement  on  the  ego  to  be  replaced,  the  realization  of  which 
is  the  great  object  of  education  {e.g.  to  make  it  moral);  l)ut  the  sole  ob- 
ject is  the  replacement  of  the  former  healthy  ego,  whether  it  may  have 
been  distinguished  by  virtues  or  obscured  by  manifold  defects.     Any  at- 
tempts at  improvement  can  only  be  useful  after  recovery.     If  the  success 
of  education  is  favored  by  i^liableness  of  disposition,  so  the  moral  treat- 
ment of  insanity  is  most  successful  where  the  ego,  already  formed,  fixed, 
and  only  temporarily  repressed,  for  a  long  time  waits  the  opportunity  to 
resume  its  former  place,  and  sometimes  even  struggles  with  all  its  powers 
against  the  disease.     Hence,  it  results  that  very  often  merely  negative 
moral  treatment  is  sufficient,  viz.  the  simple  removal  of  all  hurtful  influ- 
ences.    Is  it,  then,  wonderful  that  so  many  of  the  insane  completely 
recover  in  the  hands  of  rough  and  unskilled  jiersons? 

§  220.  As  to  the  first  indication,  namely  the  weakening  of  the  mor- 
bid dispositions,  feelings,  and  ideas,  the  most  extended  experience  shows 
that  we  seldom  arrive  at  a  favorable  result  by  directly  opposing  them. 
The  diseased  mind,  even  on  account  of  its  morbid  state,  will  not  receive 
remonstrances  and  advice,  much  less  moral  representations;  above  all,  it 
will  not  suffer  the  procedure  ordinarily  directed  against  the  bad  disiwsi- 
tions  of  persons  in  health.     This  ill-humor  proceeds  necessarily  from  dis- 
ease of  the  brain,  and  the  patient  can  no  more  divest  himself  of  it  by  an 
act  of  will,  than  the  subject  of  irritation  of  the  retina  can  escape  the 
colored  images  which  result  from  it.     Much  can  be  done  to  remove  this 
ill-humor  by  physical  treatment,  by  rational  expective  treatment,  where- 
by the  feeling  may  sometimes  be  got  rid  of  by  permitting  its  outburst  as 
in  mania;  sometimes  the  symptoms  may  be  repressed,  but  their  diversion 
by  moral  means,  which  is  soon  to  be  spoken  of,  is  always  the  principal 
object.     Quite  as  useless  and  even  more  injurious  than"such  simple  ex- 
hortation, is  any  attempt  directly  to  overcome  the  delusive  ideas  of  the 
patient  by  logical  reasoning.     All  direct,  especially  passionate,  discussion 
generally  augments  the  delusion  by  instigating  the  patient  to  justify  his 
views,  seek  reasons  for  them,  and  irritates  and  exasperates  him  according 
to  the  force  and  acuteness  of  his  opponent's  arguments;  the  raillery 
whicli  always  accompanies  such  reasoning  is  also  injurious  to  him.     The 
morbid  ideas  are  not  to  be  subdued  by  any  kind  of  proof  or  evidence.     To 
spread  all  his  wealth  before  a  patient  who  thinks  he  is  ruined,  to  pull 
down  the  wall  in  which  another  fancies  his  tormenting  enemey  is  hid, 
would  only  irritate  them  and  call  their  attention  more  forcibly  to  their 
false  ideas:  in  very  favorable  cases  we  may  obtain  an  apparent  consent  and 
compliance;  most  commonly,  however,  they  will  only  substitute  one  form 
of  delusion  for  another  of  a  worse  kind.     All  this  Avill  be  sufficiently  ex- 
plained by  what  has  been  said  (p.  50)  upon  the  manner  in  which  insane 
ideas  originate  from  dispositions  becoming  fixed;  only  by  the  removal  of 
these  is  the  insanity  to  be  thoroughly  uprooted. 

Occasional  exceptions  to  the  general  rule  not  to  attack  insanity  by 


34:4  THEKAPEOTICS. 

direct  means  of  evidence,  occur  in  convalescents  in  whom  fragments  of 
the  insane  ideas  still  remain  after  the  disappearance  of  the  disorder,  and 
also  in  the  early  stages  of  insanity,  where  the  rising  insane  notions  con- 
front the  patient  still  as  vague  images,  and  where  the  ego  still  opposing 
the  disease  can  find  help  from  the  external  view  of  the  true  state  of 
affairs.'  But,  even  in  these  cases  little  can  be  expected  from  much  ex- 
hortation and  attempts  at  conviction;  it  is  preferable  to  intimate  the  real 
condition  as  if  by  accident,  and  thus  to  let  the  patient  think  that  he  has 
arrived  at  the  conclusion  by  himself,  all  controversy  tires  and  aggi-a- 
vates,  excites  distrust  and  aversion. 

Another  means  of  direct  opposition,  to  be  reserved  for  rare  and  des- 
perate cases,  consists  in  tlie  forcible  repression  of  every  expression  of  the 
insane  ideas,  in  a  judicious  system  of  attack  on  every  insane  woz-d  or 
deed.  The  chief  means  of  this  kind  is  the  douche,  while  the  patient  is 
simultaneously  impelled  to  rational  dealings  and  expressions  partly  by 
constraint,  especially  by  the  consequent  advantages  of  freedom,  enjoy- 
ments, friendly  impressions,  etc.^  Such  open  uncompromising  attack  on 
the  insane  ideas  in  order  to  obtain  violent  mental  diversion  can  scarcely 
be  attempted  in  feome  cases  of  chronic  mania,  where  there  is  a  general  feel- 
ing of  well-being  and  an  absence  of  all  other  disturbances;  it  is  quite  as 
fatiguing  to  the  physician  as  to  the  patient,  who  should  never  have  an 
opportunity  to  indulge  in  his  insane  ideas:  suppression  of  the  hallucina- 
tions or  complete  cure,  by  such  means,  we  hold  to  be  impossible.^  The 
same  may  be  said  of  the  various  and  ingenious  artifices  and  modes  of  sur- 
prise which  have  been  employed  to  convince  the  patient  of  the  falseness 
of  his  ideas:  when  they  fail  they  actually  injure  the  patient;  he  discov- 
ers the  intention,  or  rather  deceit;  and  if  they  succeed,  they  generally 
effect  only  an  exchange  of  the  insane  ideas. 

There  are  certainly  examples  of  raj)icl  improvement  by  the  excitement  of  vio- 
lent passions,  of  anger,  fear,  etc. ,  in  mental  disease,  perhaps  most  frequently  in 
hypochondriasis.  But  apart  from  the  circumstance  that  complete  recovery  does 
not  result,  such  a  system  of  treatment  is  extremely  hazardous,  and  we  may  safely 
assume  that  for  eveiy  case  of  improvement  ten  are  made  worse,  many  of  which 
will  proceed  rapidly  to  a  state  of  incurability. 

§  221.  If  possible,  still  more  reprehensible  than  direct  opposition  is 
the  so-called  method  of  assent,  sympathy  with  the  delusion  of  the  pa- 
tient, whether  it  be  with  the  view  of  temporary  soothing,  or  possibly  to 
employ  what  is  conceded  by  the  patient  as  a  new  means  of  removing  his 
delusions.  Such  assent  will  only  confirm  the  patient  in  his  delusions; 
he  may  afterwards  appeal  to  it;  and  from  such  a  system  of  treatment, 
pursued  with  the  best  intentions,  we  often  see  the  saddest  results,  espe- 
cially in  deep  melancholic  conditions,  since  the  insane  ideas  which  the 
patient  till  then,  at  least  inwardly,  opposed  become  rapidly  confirmed. 

Instead  of  logically  arguing  against  the  insane  notions  or  confirming 
them  by  sympathy,  in  circumstances  where  a  direct  expression  is  required, 
these  will  be  much  better  opposed  by  simple  contradiction,  a  forbearing 

'  An  exceptional  case  of  this  kind,  a  very  interesting  recovery  by  means  of  ex- 
hortation, may  be  found  in  Guislain,  'Leg.  or.,'  iii.,  p.  222. 

-  See  Leuret,  '  Du  Traitement  moral  de  la  Folie,'  Paris,  1840,  and  the  later 
works  of  his  followers;  on  the  other  hand,  Blanche,  '  De  I'Etat  actuel,'  etc. 

^  This  opinion,  expressed  in  the  fii-st  edition  of  this  work,  has  since  been  con- 
firmed. ]\Iany  patients  whom  Leuret  considered  cured  were  subsequently  taken 
up  by  other  physicians  as  still  insane,  and  no  one  has  followed  Leuret's  mode  of 
treatment.  Nevertheless,  his  publication  has  done  away  with  many  prejudices, 
and  the  book  is  well  worthy  being  read. 


THERAPEUTICS.  -  34:5 

reference  to  the  future,  when  the  patient  will  be  astonished  at  his  delu- 
sions, an  allusion  to  the  past  when  he  considered  such  things  impossible. 
It  is  better,  and  generally  more  applicable,  to  leave  the  delusion  as  much 
as  possible  untouched,  and  thereby  to  weaken  it  by  want  of  encourage- 
ment, by  engaging  tlie  mind  of  the  patient  m  matters  that  have  no  ref- 
erence to  the  diseased  ideas.  This  mental  diversion  is  a  fundamental 
principle  in  all  psychical  treatment,  but  as  an  active  method  is  more 
adapted  to  chronic  than  to  acute  conditions;  it  is  effected  in  different 
cases  hy  very  various  means,  which  are  suited  to  the  case  according  as 
they  are  unresisted,  as  the  aim  of  cure  is  concealed  from  the  patient. 
Of  these  means,  the  most  important  is  employment  of  a  healthy  kind 
(see  p.  3.35);  next  to  this  stand  all  kinds  of  amusement,  entertainment, 
conversation,  which,  with  due  regard  to  individual  tastes,  should  always 
be  judiciously  selected,  so  that  whatever  tends  to  the  delusion  of  the  pa- 
tient may  be  avoided,  and  that  he  may  be  always  engaged  as  far  as  possi- 
ble in  a  healthy  subject  of  conversation.  It  is  therefore  necessary  to 
avoid,  not  only  all  reference  to  the  delusion,  the  circumstances  that  occa- 
sioned the  disease,  l)ut  also  much  direct  conversation  on  his  condition. 
The  patient  should  be  seldom  left  alone  or  unemployed;  so  long  as  he 
is  employed  with  matters  unconnected  with  his  malady,  he  is  in  a  great 
measure  free  from  it,  and  by  abstracting  his  attention  from  the  insane 
ideas,  they  are  most  readily  weakened  and  dispersed. 

§  222.  Thereby,  what  is  healthy  in  the  patient  will  be  strengthened 
and  invigorated,  and  jn-cservcd  from  suppression  and  ruin.  This  is  done 
by  whatever  promotes  and  upholds  the  ideas  and  sensations  which  char- 
acterize healthy  life,  and  this  is  the  iirinciple  of  the  rule,  to  lead  the  pa- 
tient solely,  or  at  all  events,  pre-eminently,  in  the  direction  of  his  former 
special  interests.  Again,  it  must  be  kept  in  mind  that  the  same  thing 
is  not  equally  adapted  to  every  patient.  Here  practical  knowledge  of 
mankind  on  the  part  of  the  physician  must  be  exercised  in  discovering 
the  character  by  the  different  modes  of  action  of  individuals,  Avhich  are 
regulated  by  peculiarities  in  habits,  tastes,  and  culture,  and  in  finding- 
out  the  sides  from  which  he  is  suscejitible.  In  women,  attention  is  to  be 
directed  to  other  matters  than  m  men;  in  some  cases  all  healthy  thought 
and  action  is  inseparably  connected  with  their  ordinary  employments  and 
calling  in  life;  the  mechanic  can  often  find  only  in  his  work,  the  musi- 
cian only  in  the  tones  of  his  instrument  discover,  the  whole  range  and 
unity  of  his  former  individuality.  Quite  as  varied  are  the  interests  of 
disposition;  the  attempt,  however,  always  proves  unsuccessful  to  inter- 
est the  patient  in  anything  that  has  no  foundation  or  support  from  the 
thoughts  and  pursuits  of  his  previous  life:  to  the  thoughtless,  for  exam- 
ple, religious  exhortation  during  his  disease  would  be  as  useless  as  to 
force  one  who  has  no  sense  of  harmony  to  engage  himself  with  music. 
But  the  principle  of  carefully  maintaining  and  strengthening  the  whole 
former  personality  is  to  be  departed  from  where  defects  of  character,  by 
long  control  of  the  ego,  have  evidently  tended  to  the  formation  of  the 
disease.  In  cases  which  occasionally  appear,  where  the  insanity  is  the 
last  result  of  a  life  of  dissipation  and  folly,  no  recovery  can  be  expected 
except  by  a  complete  change,  the  commencement  of  a  wQvr  individuality. 
But  it  is  well  known,  how  scanty  our  means  are  of  accomplishing  this, 
how  difficult  such  a  restitution  is,  and  how  defective  and  ahvays  suljject 
to  relapse  such  cases  are.  Everything  connected  with  the  healthy  bygone 
life — social  attachments,  the  old  modes  of  employment,  etc. — serves  to 
strengthen  the  ego,  and  the  endless  modifications  of  the  means  to  be  em- 


346  THERAPEUTICS. 

ployed  in  promoting  the  healtliy  sphere  of   tlioiiglit  (correspondence,, 
visits,  etc.)  must  be  left  to  the  judgment  and  tact  of  the  physician. 

§  223.  Of  moral  remedies,  proper  employment  of  the  patient  seems 
to  us  the  most  important.  In  healthy  work,  the  innate  desire  of  express- 
ing and  giving  vent  to  its  energies  finds  fullest  satisfaction  in  the 
objective  world  ;  by  constant  occupation  in  forming  materials,  the 
thoughts  and  efforts  engross  the  mind  and  withdraw  it  from  empty  long- 
ings and  illusions  of  the  imaginations;  the  feeling  of  success  again  pre- 
pares the  way  for  expansive  sensations,  and  therewith  self-esteem  and 
confidence  return.  Therefore,  a  steady  employment  of  the  patient,  espe- 
cially when  voluntary,  is  rightly  considered  a  decided  indication  of 
improvement,  and  is  frequently  the  commencement  of  recovery.  Those 
employments  are  the  best  whicli  keep  the  patient  engaged  in  tlie  open 
air,  as  all  garden  and  field  labor,  which  prove  of  gi'eat  advantage  not 
only  to  the  lower  ranks  who  have  been  accustomed  to  daily  toil,  but  also 
to  the  educated  classes,  owing  to  the  peaceful  and  soothing  influences  of 
immediate  intercourse  with  nature.  Where  this  is  not  practicable, 
household  or  mechanical  modes  of  employment,  chiefly  of  a  light  kind, 
may  be  substituted;  and  very  few  patients,  and  these  only  in  alternation 
with  physical  exercise  and  muscular  activity,  should  be  engaged  in 
sedentary  and  mental  work.  In  chronic  cases,  the  learning  of  a  new  and 
agreeable  trade  Avill  sometimes  engage  the  attention  in  a  most  beneficial 
way.  Indigent  patients  should  receive  a  small  remuneration  for  their 
work  during  recovery;  this  has  often  proved  a  seasonable  protection 
against  want:  the  exertions  of  the  affluent  are  devoted  to  the  institution 
and  the  poorer  inmates.  Wherever  his  state  of  health  will  admit  of  it, 
the  patient  should  work  methodically.  And  while  the  patients  are  to  be 
restrained  from  unsettled  trials  of  all  possible  employments,  every  appear- 
ance of  a  manufactory,  or  regard  merely  to  the  i")ecuniary  advantage  of  the 
institution,  is  still  more  to  be  avoided.  Eecovery  or  improvement  of  the 
patient  should  be  the  only  object  of  work.  Each  inmate  should  be  re- 
quired to  do  only  what  is  suitaljle  to  him,  and  only  at  the  proper  period, 
and  indolence  alone  is  to  be  strictly  prohibited. 

Work  is  evidently  not  adapted  to  acute  states;  in  the  exalted  stage  of  the  dis- 
ease an}-  enforcement  to  it  must  prove  injurious:  recent  cerebral  irritation  de- 
mands perfect  rest.  This  does  not,  however,  imply  that  all  mental  excitement 
renders  work  impossible  or  injurious.  In  English  asylums,  where  there  is  no  re- 
straint, many  excited  vociferous  patients  are  put  to  work,  for  example,  at  the 
washing-tub.  who,  in  many  German  asylums,  would  be  confined  in  cells;  and  it  is 
remarkable  that  they  become  sooner  calm  by  the  first  method  of  treatment.  But 
■work  is  decidedly  more  advantageous  in  the  quieter,  especially  protracted,  states 
of  insanity,  in  the  period  of  transition  to  the  secondary  forms  and  in  these  forms 
themselves,  and  during  convalescence  where  the  desire  for  work  is  spontaneous. 

§  224.  Closely  related  to  physical  employment  stands  a  healthy  en- 
gagement of  the  mental  powers.  In  asylums  "the  school"  is  a  means 
for  this  purpose  suited  to  many  of  the  patients.  This  is  not  intended  to 
combat  the  insane  ideas  of  the  patient,  or  to  demonstrate  by  philoso- 
phy the  impracticability  of  his  projects,  but  to  withdraw  his  atten- 
tion from  the  morbid  ideas  to  matters  which  are  interesting  and  useful. 
It  is  a  useful  means  of  awakening  the  mind  and  of  imparting  the  elements 
of  mental  culture  to  patients  who  were  previously  ignorant.  Like  all  em- 
ployment which  excites  the  brain,  it  ought  never  to  be  permitted  in  the 
acute  stages,  and  in  all  other  Cases  it  should  be  continued  only  for  a  com- 
paratively short  time.  The  subjects  of  instruction  are  regulated  according 
to  age,  sex,  and  education,  and  consist  of  elementary  instruction  in  music, 


THERAPEUTICS.  34T 

history,  etc.  It  may  be  combined  with  recitation,  and  can  with  advantage 
be  conducted  on  the  principle  of  mutual  instruction;  the  more  educated 
patients  assisting  the  uneducated,  always  remembering  tliat  teacher  and 
method  must  be  made  attractive  to  the  patient.  Too  much  has  frequently 
been  anticipated  from  the  influence  of  music;  the  sentiments  provoked 
by  it  are  too  transient  to  oj^pose  the  duration  of  the  moi'bid  disposition^ 
and  it  has  no  influence  beyond  other  means  of  distraction,  except  when 
it  is  the  decided  choice  of  the  patient.  The  practice  of  part-singing  in 
asylums  is  to  be  commended  as  a  means  of  amusement. 

Besides,  conversations,  lectures,  Avalks,  games,  tea-parties,  etc.,  also 
serve  to  engross  and  amuse  the  patient.  These  are  to  be  regulated  as 
much  as  possible  to  suit  the  diflierent  dispositions. 

Guislain  lias  very  properly  declared  himself  against  those  promiscuous  dancing 
parties  so  common  in  several  English  institutions,  and  which  have  been  imitated 
in  other  countries.  In  a  great  German  city  the  newspapers  annually  contain  the 
announcement  of  a  brilliant  ball  at  the  lunatic  asylum,  with  the  insulting  inti- 
mation that  the  company  was  not  disordei'ly. 

Visits  to  the  patients  should  always  be  under  special  surveillance,  and 
the  simply  curious  siiould  be  altogether  excluded.  In  the  early  periods, 
and  when  the  disease  is  still  increasing,  visits  from  the  relations  are  ordi- 
narily hurtful,  partly  by  affording  nourishment  to  the  frequent  aversion 
of  the  patient  towards  his  relations,  and  recalling  many  irritating 
thoughts;  partly  by  hindering  the  necessary  habitude  and  resignation  of 
the  jDatient  to  his  residence  in  the  asylum,  and  exciting  longings  for 
home.  On  the  contrary,  when  the  patient  is  calm,  and  healthy  desires 
are  again  awakened,  visits  contribute  much  towards  his  improvement  and 
strength.  In  commencing  convalescence,  the  patient  often  after  a  single 
visit  quickly  discovers  his  real  condition,  the  nature  of  his  disease,  and 
his  relation  to  the  Avorld. 

§  225.  The  aid  of  religion  in  the  treatment  of  insanity  is  not  to  be 
lightly  estimated;  the  application  of  this  remedy  requires,  however,  great 
caution.  Keligious  instruction  should  not  be  withheld  from  any  patient 
who  desires  and  requires  it;  it  would,  however,  oppose  the  first  principles 
of  mental  treatment  to  enforce  such  instruction,  or  attempt  to  interest  in 
it  any  one  who  has  no  religion  at  heart.  It  would  show  total  ignorance 
of  the  nature  and  circumstances  of  tbose  diseases  to  aim  at  direct  recovery 
by  reforming  or  converting  the  patient  by  religious  instruction.  All  such 
means  should  only  aim  at  imparting  quietude,  trust,  and  hope — to  direct 
attention  from  the  morbid  representations  to  an  earnest  and  remarkable 
theme — to  revive  the  modes  of  thought  and  sensation  of  his  healthy  state. 
How  far  such  ends  should  be  attempted  by  these  means  can  only  be 
judged  by  the  physician.  He  will  never  comply  with  the  cruel-and  useless 
request,  that,  in  addition  to  his  self-tormentmg  misery,  a  melancholic 
patient  should  be  subjected  to  severe  penance,  or  that  the  timid  and  fear- 
ful  be  threatened  with  the  torments  of  hell.  Melancholies  and  maniacs, 
unless  all  excitement  of  this  kind  has  ceased  to  influence  them,  confirmed 
maniacs,  gladly  seize  all  such  representations  to  nourish  their  delirium. 
Should,  however,  the  religious  influence  be  exerted  with  the  necessary 
circumspection — if  only  those  phases  of  religion  be  presented  which  sea- 
sonably appeal  to  the  feelings,  and  if  the  chaplain  be  judicious  enough 
to  have  in  view  the  single  aim  of  the  patient's  recovery — regular  religious 
services  according  to  both  creeds  is  highly  beneficial,  and  we  very  often 
see  the  chaplain's  visit,  indejiendently  of  what  he  says,  proving  of  great 
advantage  to  the  patients,  owing  to  the  necessity  of  their  meeting  together 
for  some  time. 


3i8  THERAPEUTICS. 

Several  medical  psychologists  would  have  the  whole  treatment  of  the  insane  to 
be  speciticaliy  Christian.  But  Jews  also  require  tlie  aid  of  the  alienist  and  his 
science,  and  there  is  no  abstract,  only  a  confessional  Christianity.  Therefore 
there  would  require  to  be  a  special  Protestant,  CathoUc,  etc.,  and  again  a  Jewish, 
heathen,  psychiatrie.     Possibly  even  this  may  be  yet  desired. 

§  226.  External  means  of  restraint  are  employed  with  the  view  of  pre- 
venting the  patient  from  inflicting  injury  to  himself  or  others,  to  prevent 
that  vdire  and  fury,  especially  such  manifestations  of  his  insane  desires  as 
would  afford  them  new  nourishment,  and  thereby  to  aid  his  self-control. 
Besides,  they  should  serve  to  make  him  sensible  of  an  external  force 
ao-ainst  which  his  own  exertions  are  powerless,  to  bend  liis  will,  and  sub- 
due obstinacy  and  a  refractory  spirit.  The  means  employed  should 
never  be  such  as  in  the  least  to  wound  tlie  self-esteem  of  the  patient;  they 
should  never  be  suggestive  of  a  house  of  correction  (as  chains  and  blows), 
neither  should  they  shock  the  imagination,  as  did  those  great  apparatus 
which  were  used  till  very  recently  in  many  places.'  At  the  present  day, 
the  strait-jacket  (which  is  of  linen)  is  the  principal  moans  of  restraint 
still  in  use;  it  allows  to  the  patient  little  or  no  use  of  his  arms  and  hands. 
In  many  asylums  the  constraint-chair  is  still  used— an  arm-chair  in  which 
the  patient* is  confined;  straps  also  to  fasten  him  down  in  bed. 

It  was  abuses  which  formerly  Avere  invariably  connected  with  the  em- 
ployment of  bodily  restraint  which,  about  twenty  years  ago,  originated 
in  England  the  opposite  system,  the  total  banishment  of  all  means  of 
mechanical  restraint  from  the  treatment  of  insanity.  This  method  known 
as  the  system  of  non-restraint,  first  (1838)  tried  by  Gardiner  Hill  in  the 
Lincoln  Asylum,  was  fully  developed  by  Conolly  in  Hanwell  in  1839,  and 
within  the  last  ten  years  has  been  adopted  in  nearly  all  English  asylums. 
Its  advantages  have  been  as  much  praised  as  they  have  been  disputed. 
The  principal  argument  in  favor  of  tliis  system,  is  its  greater  humanity 
and  its  easier  quieting  of  the  patient,  Avho  is  often  rendered  more  irritable 
by  mechanical  coercion.  It  has  been  affirmed  that  the  patient  is  thus  more- 
habituated  to  self-observation  and  control,  that  he  is  raised  in  his  own 
esteem,  and  that  by  it  arbitrary  violence  on  the  part  of  the  attendants  is 
rendered  impossible.  It  is  alleged  that  in  those  asylums  Avhere  this 
method  has  been  adopted  the  patients  have  been  rendered  calmer,  more 
submissive  and  clieerful,  and  the  recoveries  more  numerous  and  perma- 
nent. In  occasional  rare  cases  of  necessity,  the  use  of  mechanical  means 
is  nevertheless  conceded  (Conolly). 

On  the  other  hand,  it  is  argued  that  it  is  an  excess  of  philanthropy  to 
consider  it  an  act  of  inhumanity  to  confine  a  lunatic  with  the  strait- 
jacket;  that  mechanical  restraint  aloue  is  capable,  in  certain  cases,  of 
rendering  them  submissive  to  the  authority  of  the  physician,  and  harm- 
less to  themselves  and  others;  that  the  use  of  these  means  allows  the 
patient  himself  more  freedom,  especially  to  move  in  the  open  air;  that 
without  them  a  disproportionately  large  staff  of  attendants  is  necessary; 
that  a  personal  control  is  more  irritating  than  mechanical  means;  that 
some  patients,  when  they  feel  a  paroxysm  of  madness  coming  on,  even 
desire  mechanical  restraint,  especially,  however,  in  occasional  cases  of 
suicidal  tendency  (there  being  no  other  means  of  control);  and  lastly, 
that  the  seclusion  which  is  employed  in  the  system  of  non-restraint  is 
equally  mechanical  coercion  under  a  different  but  not  improved  form. 

In  taking  a  retrospect  of  these  arguments  for  and  against,  we  can 

'  For  an  enumeration  of  these,  see  Schneider's  '  Heilmittellehre  gegen  psychi- 
sche  Krankheiten,'  Tubingen,  1824. 


THEEAPKUTIC8.  349" 

easily  understand  how  the  yalne  of  the  system  of  non-restraint  was  so 
long  questioned,  and  how  the  arguments  against  it  appeared  to  keep  the 
ascendancy.  But  if  we  consider  that  these  objections  proceeded  entirely 
from  those  who  had  not  practically  tested  the  system  of  non-restraint, 
and  had  never  even  ^witnessed  it,  their  force  will  not  aiypear  so  great.  If 
Ave  interrogate  experience,  which  is  the  only  proper  test,  we  shall  find 
that  during  the  last  ten  years  all  doubts  in  reference  to  it  have  been  re- 
moved. The  question  is  now  decided  entirely  in  favor  of  non-restraint. 
This  great  reform  is  now  carried  out  with  the  most  favorable  results  in 
every  ])ublic  asylum  in  England,  and  the  name  of  Conolly  will  always  be 
mentioned  with  that  of  Pinel,  whose  work  he  has  completed. 

The  exact  method  of  this  system  is  by  many,  however,  not  properly 
understood.  It  consists  of  an  entire  setting  aside  of  all  mechanical  means 
of  restraint,  and  the  substitution  of  other  means  of  quieting  and  watching 
the  patient.  The  new  system  is  therefore  a  positive  treatment,  not  a 
mere  leaving  of  the  patient  to  himself;  still  less,  as  has  recently  been  un< 
justly  asserted,  is  it  the  supplying  the  place  of  mechanical  restraint  by 
coercion,  by  seclusion,  or  restraint  by  the  hands  of  attendants.'  The 
system  of  repressing  the  manifestations  of  the  disease  by  mechanical  re- 
straint and  violence  is  exchanged  for  a  mild  system  of  treatment,  which, 
in  the  majority  of  cases,  can  avert  those  manifestations;  where  this,  how. 
ever,  does  not  succeed,  some  other  means,  conciliatory  or  simply  quieting, 
is  devised  to  meet  the  case.  If,  then,  it  should  be  asked  what  in  these 
asylums  is  put  in  the  place  of  mechanical  restraint,  which  was  hitherto 
indispensable?  we  have  only  to  say,  that  according  to  indisputable  evi- 
dence, in  thcasylums  where  there  is  no  restraint  and,  at  the  same  time, 
good  dietetic  and  therapeutic  treatment,  the  cases  which  appeared  to  de- 
mand restraint  have  steadily  and  remarkably  diminished;  that  there  are 
rarely  seen  any  of  those  cases  of  continued  and  violent  mania  which  are 
still  treated  in  many  places  by  means  of  prolonged  seclusion,  the  use  of 
the  strait-jacket,  or  the  constraint-chair.  Should,  however,  violent  ex- 
citement present  itself,  Ave  seek,  by  means  suited  to  each  particular  case, 
to  distract  the  patient's  attention  from  the  object  of  his  delirium,  to  calm 
and  to  diA'ert  him;  he  is  removed  from  the  locality  where  his  agitation 
commenced,  and,  if  necessary,  isolated  for  a  short  time  (tAvo  to  four 
hours,  often  less)  in  a  chamber  Avhere  he  is  secure  against  self-injury,  or 
confined  in  an  inclosed  court.  In  all  communication  Avith  an  excited 
patient  the  greatest  forbearance  and  gentleness  must  be  exercised,  and 
everything  Avhich  has  the  least  appearance  of  violence,  or  could  in  any 
way  irritate  him,  ought  to  be  avoided.  This  system,  which  is  so  much 
to  be  preferred  to  the  old  mode  of  coercion  still  practised  in  many  places, 
can  naturally  only  be  carried  out  in  an  institution  so  organized  as  to 
meet  its  demands;  the  attendants  must  be  sufficiently  numerous,  intelli- 
gent, actiA'e,  and  good-natured,  and  all  must  be  under  the  constant  sur- 
veillance of  a  physician  Avho  takes  great  interest  in  the  subject,  and  is  of 
a  patient  and  benevolent  disposition. 

In  certain  rare  and  exceptional  cases  (such  as  sudden  protection 
against  a  dangerous  lunatic,  surgical  cases,  etc.)  Conolly  himself  admits 
tiie  possibility  of  the  necessity  of  employing  (for  as  short  a  time  as  possi- 
ble) mechanical  restraint:  this  is  totally  different  from  its  employment  as 
a  means  of  regular  treatment  of  the  insane.     In  all  the  cases  Avhere  for- 

'  With  regret  I  find  this  opinion,  so  fundamentally  false,  even  in  Neuman, 
Psychiatrie,'  p.  86.     The  ardor  with  which  the  author  defends  the  strait-jacket 
should  not  have  led  him  to  such  incorrect  expressions. 


350  THERAPEUTICS. 

merly  force  appeared  indispensable,  even  in  those  with  a  tendency  to 
suicide,  experience  has  proved  tlio  entire  abolition  of  all  such  means,  and 
their  substitution  by  milder  measures  which  act  upon  the  disposition  of 
the  patient,  to  be  in  every  way  more  suitable. 

Up  to  the  time  of  the  publication  of  the  first  edition  of  this  work,  I  allowed 
myself,  influenced  by  the  adverse  opinions  of  the  German  psychologists,  to  oppose 
the  system  of  non-restraint;  although  at  heart  I  sympathized  with  the  reforms, 
yet  r  could  not  see  my  way  clear  to  refute  the  contrary  arguments  which  were 
advanced.  Since  then  practical  experience,  from  the  cne  end  of  England  to  the 
other,  has  done  so.  I  have  seen  the  new  system  carried  out  in  several  of  the  large 
English  institutions,  and  have  been  convinced.  Indeed,  in  one  of  the  institutions 
containing  about  1,000  patients,  I  saw  a  bloody  nose  and  heard  the  crash  of  broken 
glass,  but  I  have  remarked  the  same  in  asylums  where  the  strait-jacket  and  con- 
straint-chair were  in  daily  use.  I  have  seen  with  happy  astonishment  how  easily 
several  patients  on  the  point  of  an  outbreak  were  rendered  speedily  calm  through 
a  kind  of  psychical  diversion,  who  to  a  certainty,  in  the  majority  of  Continental 
institutions,  would  at  once  have  had  means  of  restraint  api^lied.  Let  us  hear  no 
more  of  impossibility!  In  Hanwell,  with  a  population  which  has  gradually  in- 
creased till  now  it  reaches  about  1,000,  for  twenty-one  years  there  has  not  been  a 
hand  or  foot  bound  either  by  night  or  by  day.  Colney  Hatch,  a  very  large  asylum 
(1,200  patients)  was  opened  in  1849,  and  never  to  this  day  has  any  means  of  re- 
straint been  employed;  Bedlam  and  St.  Luke's  which  are  specially  devoted  to 
acute  cases,  have,  to  the  great  benefit  of  these  institutions,  long  ago  embraced  the 
system  of  non-restraint,  and  not  one  of  the  asylums  in  which  the  new  system  has 
been  introduced  has  reverted  to  the  old  treatment.  Nor  let  it  be  said  that  in  the 
system  of  non-restraint  confinement  in  a  cell  is  "also  restraint,"  a  substitute  for 
the  strait- jacket.  Amongst  5-6,000  patients  in  a  number  of  English  asylums, 
Morel  found  (1.  c,  p.  55)  only  three  in  cells,  and  in  these  cases  the  periods  of  con- 
finement were  short.  Compare  with  this  the  numbers  who  are  confined  in  cells — 
many  with  strait-jackets,  and  othei's  actually  reconciled  to  their  sojourn  through 
its  long  continuance — in  some  of  our  Continental  asylums  wheVe  non-restraint 
seems  to  be  regarded  as  a  mere  chimera.  And  let  it  no  more  be  repeated  that 
sucli  a  system  is  suited  only  to  the  English,  who  submit  more  easily  to  control 
than  the  patients  on  the  Continent.  Before  the  time  of  ConoUy  it  was  believed 
in  England  also  that  it  was  impossible  to  treat  the  insane  without  powerful  means 
of  restraint;  even  as  recently  as  1843,  in  Bedlam  and  St.  Luke's  the  patients  were, 
owing  to  their  presumed  ferocity,  fastened  in  rows  to  the  walls.  Neither  let  it  be 
said  that  the  use  of  means  of  restraint  is  good,  and  that  only  the  abuse  is  blame- 
able.  No  one  can  say  where  the  use  ends  and  the  abuse  begins;  indeed,  it  would 
appear-  that  the  abuse  is  unavoidable,  and  a  very  experienced  physician  has  said 
"restraint  is  synonymous  with  neglect  "  (ConoUy). 

Let  us  then  i)ursue  with  confidence  the  new  system,  fearlessly  break  off  the 
old  customs  and  assume  the  new  responsibilities,  ever  remembering  that  the  least 
negligence  wiU  re-open  the  gates  to  the  employment  of  violence.  This  is,  how- 
ever, a  more  difficult  task  than  to  amuse  the  public  with  pleasing  descriptions  of 
Christmas  presents  at  asylums  where  the  wretched  constraint-chair  still  flourishes. 
The  example  of  the  perseverance  with  which  the  English  physicians  have  carried 
out  the  new  principles  is  encouraging,  and  still  more  so  are  the  results.  If  we 
quietly  begin  to  inquire  how  many  patients  have  been  really  benefited  by  means 
of  restraint,  we  will  be  led  to  ask  ourselves  whether  the  arguments  against  non- 
restraint  are  not  the  same  which,  seventy  years  ago,  were  advanced  against  the 
first  removal  of  the  coarse  and  barbarous  fetters  by  Pinel.  At  all  events,  let 
every  one  keep  a  register  in  which  each  instance  of  the  employment  of  restraint 
is  entered,  with  the  cavise,  nature,  duration,  and  effect,  and  inquire  at  the  end  of 
the  year  what  it  has  effected  for  the  cvire  and  improvement  of  the  patients,  and 
how  far  it  has  justified  the  confidence  reposed  in  it.  We  doubt  not  that  ere  long, 
in  every  new  institution,  with  the  very  foundation-stone  the  assurance  will  be 
laid,  that  for  all  time  coming  the  system  of  restraint  is  excluded.  For  the  litera- 
ture on  this  subject,  see  Conolly,  '  On  the  Treatment  of  the  Insane  without 
Mechanical  Restraint;' Dick,  'Zeitschr.  f.  Psych.,'  xiv.,  1856,  p.  353;  Morel.  '  Le 
Non-restraint,'  Paris,  1861. 


THERAPEUTICS.  351 

Section  IV. —  Various  Modifications  of  Treatment. 

§  227.  The  means  hitherto  discussed  must  be  essentially  modified  on 
their  application,  according  to  the  particular  form  of  insanity,  from 
which  the  patient  suffers;  the  mental  and  physical  treatment  have  again 
to  be  modified  as  well  by  differences  of  individuality  as  by  differences  of 
form,  by  the  presence  of  other  bodily  diseases  which  may  be  the  same  in 
all  forms,  and  especially  according  to  the  differences  of  social  status,  dis- 
position, and  mental  character.  For  the  last-mentioned  particular  no 
general  rules  can  be  established.  In  the  treatment  of  the  different  stages 
of  insanity,  and  particularly  at  the  commencement,  the  necessity  of 
prompt  and  early  interference  must  again  be  insisted  on.  First,  by  a 
careful  and  minute  observation  of  the  patient  the  diagnosis  is  to  be  cer- 
tainly established.  Where  the  first  indications  are  moderate,  it  may 
happen  that  only  a  probable  diagnosis  can  be  made,  which,  however,  can 
be  further  supported  by  evidence  of  the  existence  of  hereditary  disposi- 
tion, of  certain  causes  having  been  at  work,  etc.  Always  avoiding  any 
gross  error,  such  as  confounding  typhus  fever  with  insanity,  it  is  a  judi- 
cious course  for  the  patient  where  there  is  strong  presumption  of  it  to 
treat  him  as  if  he  were  insane,  as  from  this  course  no  injury,  but  proba- 
ble benefit,  can  ensue.  For  at  this  period  the  chief  treatment  is  con- 
fined to  avoiding  all  causes  of  the  disease,  and  to  careful  dietary  arrange- 
ments suited  to  his  case. 

It  is  here  that  physical  treatment  is  most  extensively  employed:  as  to 
moral  treatment,  the  patient  is  to  be  guarded  against  too  eagerly  engaging 
himself  with  adverse  circumstances,  which  increase  his  ill-humor;  from 
all  exciting  argument,  all  urgent  exhortation  or  religious  discussion. 
On  the  other  hand,  his  mental  pain,  as  far  as  possible,  is  allayed  by  dis- 
tracting his  attention  by  other  subjects,  by  directing  it  to  the  sphere  of 
his  accustomed  duties,  or  to  mild,  cheering  external  influences:  and  his 
sinking  hopes  are  to  be  strengthened  by  moderate  and  benevolent  en- 
couragement. The  patient  should  not  be  allowed  to  discover  that  any 
doubt  is  entertained  regarding  his  mental  health,  that  he  is  directly 
observed;  nor  should  he  be  urgently  questioned  regarding  the  reasons  of 
his  change,  which  would  cause  him  to  be  distrustful  and  inclined  to  dis- 
simulate; he  should  be  as  little  as  possible  left  alone.  It  is  sometimes, 
however,  advantageous  to  observe  him  when  he  thinks  himself  alone  and 
unnoticed,  as  then  lie  often  gives  way  to  soliloquy  and  gesticulation. 
Wherever  the  general  health  permits,  he  should  not  be  altogether  idle — 
a  suitable  employment  should  be  chosen  for  him;  but  all  mental  exertion 
is  to  be  entirely  avoided,  and  frequently  the  first  step  in  treatment  is  the 
entire  cessation  of  the  previous  occupation. 

The  patient  should  in  every  instance  be  withdrawn  from  the  baneful 
influences  which  have  hitherto  been  at  work,  and  conducted  to  others 
which  are  new  and  beneficial.  In  order  to  arrive  at  this,  a  total  change 
of  all  the  external  relations  is  frequently  necessary;  very  beneficial  results 
are  often  obtained  by  change  of  scene,  short  excursions,  if  possible,  on 
foot,  and,  if  the  circumstances  permit,  a  residence  at  some  carefully 
selected  watering-place — never  in  great  cities,  where  the  brain  and  senses 
of  the  patient  may  be  excited.  All  exciting  amusements — the  theatre, 
music  parties,  and  the  various  "pleasures"  that  one  might  be  tempted  to 
permit — can  only  do  injury.  The  patient,  above  all,  requires  prevention 
of  violent  impressions  of  contact  with  those  who  are  not  acquainted  with 
the  nature  of  his  malady,  and  quiet  and  stilhiess.     The  success  or  uon- 


352  THERAPEUTICS. 

success  of  these  rules  depends  very  much  on  the  degree  of  patience  and 
perseverance  with  wliicli  they  are  carried  out,  on  tlie  external  conditions 
of  the  patient,  and  on  those  who  surround  him;  and  the  aid  of  an  intelli- 
gent woman  is  often  valuable.  The  physician  must  counteract  tlie  error, 
so  frequently  committed  by  relations,  of  considering  the  mental  anomaly 
as  if  it  depended  upon  waywardness  and  dissimulation;  he  must  kindly 
yet  decidedly  acquaint  them  with  the  danger  in  which  the  patient  stands, 
and  the  necessity  of  immediate  interference;  he  must  not  accept  auy 
excuse  when  he  observes  that  his  instructions  are  not  implicitly  attended 
to. 

Moreover,  a  regulated  diet,  exclusion  of  all  alcoholics,  abundant  out- 
door exercise,  refreshing  sleep,  and  a  healthy  maintenance  of  all  the 
secretions,  must  be  seen  to.  AH  symptoms  of  acute  or  chronic  disease  in 
other  parts  (menstruation,  heart-disease,  diseases  of  the  bowels,  etc.) 
must  be  carefully  watched,  and  anything  that  could  determine  or  main- 
tain hypera^mia  or  irritation  of  the  brain  must  be  unremittingly  and 
attentively  treated.  Although  it  bo  true  that  all  treatment  having  a 
specially  weakening  effect  is  to  bo  avoided,  yet  it  is  in  this,  the  stage  of 
commencement,  when  the  disease  is  acute,  that  well-directed  blood- 
letting, if  si^ecially  indicated,  can  have  the  best  results. 

Treatment  by  mineral  waters  at  the  commencement  of  insanity, 
especially  by  slightly  laxative  waters,  as  Marienbad,  Kissmgen,  etc.,  is, 
to  say  the  least,  useless.  Systematic  hydropathic  treatment  is  generally 
still  more  injurious;  tepid  thermal  baths,  if  the  change  be  in  other 
respects  beneficial,  may  have  a  calmative  effect  upon  certain  patients. 
The  nutrition  must  be  improved,  in  some  cases,  directly,  by  means  of 
stimulating  nourishment — iron,  cod-liver  oil,  or  by  a  lighter  diet,  as 
milk;  in  others,  indirectly,  by  improvement  of  the  digestion  and  sleep. 
All  states  of  congestion  must  be  opposed  (cold  applications,  sinapisms, 
cooling  remedies,  leeches,  etc.);  the  excretions  maintained,  nervous 
agitation  calmed,  and,  if  possible,  sleep  reinduced  (baths,  opium,  aq. 
lauro-cerasi,  digitalis,  etc.).  Removal  to  a  quiet  country  residence, 
together  Avitli  a  simple  mode  of  life,  does  good  in  many  instances. 
Moderate  exercise,  long-continued  rest  of  the  body  (so  that  the  greater 
part  of  the  day  is  spent  in  bed — the  remainder,  if  possible,  quietly  in  the 
open  air),  or  constant  rest,  should  be  jjrescribed  according  to  the  case.' 

§  2:28.  When  the  commencement  of  the  disease  is  sudden,  and  its 
outbreak  violent,  wo  should  not,  merely  to  calm  for  a  time  the  most 
striking  symptoms,  be  induced  to  adopt  thoughtlessly  the  use  of  means 
which  might  exert  an  injurious  influence  iTpon  the  subsequent  course  of 
the  disease  (for  example,  profuse  bleeding,  tartar  emetic  in  large  doses). 
In  such  cases  there  should  only  be  added  to  the  treatment  previously 
mentioned,  comjilete  isolation  of  the  patient,  who  can  no  longer  mix 
with  the  world. 

In  melancholia,  all  attempts  to  repress  the  mental  pain  Avith  questions 
and  exhortations  should  be  avoided.  The  patients  should  be  spoken  to 
as  little  as  i>ossible  about  their  own  condition,  and  not  at  all  regarding 
the  object  of  their  delirium;  they  should  not  be  permitted  to  make  many 
complaints,  and  a  somewhat  strict  system  of  treatment,  which  may  oc- 
casionally even  have  the  appearance  of  severity,  is  often  of  more  service 

'  See  Erlenmeyer,  "  How  are  Mental  Diseases  to  be  treated  at  their  com- 
mencement?" Neuwied,  1861;  Guntz,  "How  are  Mental  Diseases,"  etc.,  'Arch. 
derGesells.  f.  Psych.,'  iii.,  1,  1860,  p.  1. 


THEKAPEUTICS.  353 

than  words  of  consolation.  The  stronger  patients  should  rise  regularly 
in  the  morning,  do  some  work,  take  a  walk,  etc. ;  those  who  are  weakly, 
especially  females,  and  patients  Avith  weak,  irritable  action  of  heart,  and 
dry,  cold  skin,  may  be  jiermitted  to  lie  long  in  bed;  their  harmless 
wishes  are  to  be  attentively  fulfilled,  every  healthy  feeling  encouraged, 
and  only  what  is  morbid  resisted.  When  great  anxiety  and  restlessness 
apiDcar,  especially  in  the  agitated  form  of  melancholia,  all  active  repres- 
sion is  objectionable;  it  is  best  treated  by  regulated  exercise  in  the  open 
air,  the  use  of  baths,  etc.  In  these  cases,  the  remedies  that  are  employed 
in  intestinal  catarrh,  and  occasionally  emetics,  are  of  service — more  fre- 
quently the  milder  laxatives,  which  may  sometimes  be  combined  with 
bitters.  In  many  cases,  digitalis,  tonics,  quinine,  are  indicated — excep- 
tionally a  little  wine;  above  all,  however,  opium  in  large  doses  (see  p. 
346).  In  melancholia  with  stupor,  drastic  cathartics,  and  strong 
external  irritants — vesicatories,  tartar-emetic  ointment — are  often  useful; 
the  bodily  strength  is  to  be  improved  by  means  of  good  nourishment. 

In  mania,  the  removal  of  the  patient  from  former  scenes  is  always 
indispensable.     The  maniac  who  has  forgotten  all  ideas  of  order  and  of 
healthy  life,  and  who  may  become  very  dangerous,  and  the  monomaniac 
who,  through  the  opposition  with  which  his  extravagant  undertakings 
and  eccentric  demands  are  met,  becomes  soon  exasperated,  can  only  be 
tolerated  in  an   asylum,   and,   above  all,   can  only  be   treated  there. 
Kothing  is  more  injurious  to  them  than  uncontrolled  freedom,  which 
constantly  increases  the  malady;   while  the  rest  and  quietness  of  the 
asylum,  Avith   its  restraining   influences,  have  in   many  an   immediate 
beneficial  effect.     Even  there,  unruly  patients  generally  require  to  be 
isolated,  it  may  be  for  only  a  short  time.     Some  require  complete  rest 
and  quietness — in  rare  cases  the  withdrawal  of  light;  many  are  soonest 
rendered  quiet  by  being  allowed  free  vent  to  their  humor  in  large  pro- 
tected rooms,  or  better  in  the  open  air.     Moreover,  the  outward  excite- 
ment should  not  be  immediately  opposed  by  means  of  restraint,   and 
quite  as  little  by  exhortations  and  counsels.     It  is  best  to  allow  such 
patients  to  speak  and  to  cry  unheeded;  and  the  outbreaks  of  temper  should 
only,  when  of  a  dangerous  nature,  or  where  they  might  originate  ncAV 
internal  excitation,  be  restricted  by  mental  diversion  or  isolation,  which 
should   be   carried  out   promptly,  without   any  talking   or  struggling. 
Everything  not  positively  injurious  may  be  granted  to  the  patients;   but 
we  should  not  give  in  to  extravagant  demands,  and  not  show  ourselves 
too  indulgent  to   the  morbid  Avishes.     In  occasional  cases,  indeed,  es- 
pecially if  we  may  presume  from  former  attacks  that  the  mood  Avill  only 
last  for  a  short  time,  it  is  often  better  to  satisfy  even   unnecessary 
demands.     Uproarious,  disobedient  patients,  even  though  highly  refined, 
must  be  subdued  at  any  price;   indulgence  only  increases  their  demands, 
and  awakens  the  idea  that  they  can  impose  upon  the  physician.     Where 
there  seems  to  be  suflBciont  mind,  we  may  say  to  the  patient  that  he  is  ill, 
and  call  his  attention  to  the  anomaly  of  his  acts  and  pursuits;   Avhere 
possible,  the  patient  should  be  exhorted  to  a  proper  demeanor,  and  after 
a  time  put  to  some  emjiloyment.     Such  patients  should  be  allowed  to 
drink  a  great  deal — to  use  baths  in  the  manner  described.     Leeches  and 
cupping  maybe  employed  when  necessary;   also  digitalis,  cooling  medi- 
cines, and  slight  ai^erients;   very  seldom  (except  in  delirium  tremens) 
should  narcotics  be  given.     Cutaneous  irritants  seldom  do  good  in  acute 
cases.     In  general,  it  is  necessary  in  these  cases  to  guard  against  doing 
23 


354:  THERAPEUTICS. 

too  mucb,  remembering  that  outward  quiet  is  not  the  sole  aim  of  treat- 
ment, and  that  the  nutrition  is  to  be  maintained  as  much  as  possible. 

There  is  no  specific  treatment  for  puerperal  mania,  although  such  has  been 
often  recommended.  Each  case  must  be  treated  according  to  the  form  it  presents. 
The  chief  consideration  is  always  whether  any  other  (always  feverish)  puerperal 
disturbance  be  present  (see  p.  145):  if  so,  it  is  the  principal  object  of  treatment;  if 
not,  if  the  cerebral  affection  does  not  depend  upon  other  disease,  then  all  violent 
measures,  especially  bloodletting,  cathartics,  cutaneous  irritants,  are,  as  a  rule, 
wholly  to  be  avoided,  and,  on  the  contrary,  nourishing  diet,  keeping  the  bowels 
gently  open,  and  quieting  the  excitement  by  means  of  baths  and  opium,  are,  in 
the  majority  of  cases,  the  chief  means  of  treatment.  In  cases  where  there  is  con- 
siderable anasmia,  small  quantities  of  alcohol  may  be  advantageously  given;  in 
other  cases,  digitalis,  camphor,  and  quinine  are  useful.  The  same  remarks  apply 
to  the  treatment  of  hysterical  mania.  Where  there  is  acute  delirium  (see  p.  212), 
cold  affusion  in  a  tepid  bath  often  does  good;  a  rapid  sinking  of  the  nutrition  in 
this  form  demands  particular  attention. 

It  is  difficult  to  define  more  precisely  the  rules  of  treatment  in  the  de- 
generate chronic  forms  of  mania  and  melancholia  which  pass  into 
dementia.  Each  case  must  be  individually  considered  and  the  therapeu- 
tical and  moral  treatment  cannot  be  too  early  commenced.  All  marked 
changes  in  the  bodily  health  are  to  be  carefully  watched,  as  they  some- 
times favorably  modify  the  insanity.  The  great  point,  however,  is  to  re- 
excite  the  spontaneity  of  the  patient.  This  may  be  sometimes  brought 
about  by  a  complete  change  of  the  external  relations,  as  removal  to 
another  asylum,  or  temporary  discharge  by  way  of  trial.  ^  That  system  of 
treatment  which  attempts  to  bring  about  this  result  by  violent  repression 
of  all  morbid  manifestations,  and  forcing  the  patient  to  healthy  acts  and 
desires,  has  not  been  justified  by  its  results. 

In  fully  developed  systematic  mania,  and  in  dementia,  treatment  is 
restricted  to  protection  of  the  patient,  by  work,  strict  discipline,  order, 
and  cleanliness,  from  deeper  mental  and  bodily  degradation,  and  to 
rendering  his  existence  as  comfortable  as  possible  by  benevolent  treat- 
ment, and  by  allowing  him  all  the  enjoyments  he  may  desire,  and  which 
his  state  permits  us  to  accord. 

For  paralytic  dementia  there  is  no  therapeutical  treatment.  Several 
observers,  hoAvever,  state  that  they  have  seen  benefit  result  from  the  use 
of  the  actual  cautery;  others,  from  methodical  and  long-continued  appli- 
cation of  cupping-glasses — dry,  or  with  the  abstraction  of  only  a  small 
amount  of  blood — to  the  nvicha,  from  strict  diet  (in  some  cases  milk 
diet),  evacuants,  iodide  of  potassium,  the  mineral  acids,  etc.  ^  As  the  dis- 
ease advances,  the  utmost  cleanliness  (but  to  the  total  exclusion  of  baths) 
is  to  be  seen  to;  well-chosen  nourishing  diet,  consisting  towards  the  end 
of  semifluid  elements;  above  all,  pure  air,  the  patient  being  as  much  as 
possible  in  the  open  air;  and,  in  short,  the  same  attention  is  required 
which  is  necessary  in  tlie  earliest  years  of  childhood — anything  that  can 
prolong  life  and  make  it  more  supportable. 

The  treatment  of  the  various  states  of  idiocy,  whether  congenital  or 
occurring  in  early  years,  if  recovery  (which  is  extremely  rare)  or  simple 
improvement  he  aimed  at,  must  be  commenced  in  the  years  of  childhood. 
Adult  idiots  and  cretins  can  only  be  subjects  of  care  and  protection.  To 
arrive  at  real  results,  the  treatment  must  be  begun  at  the  earliest  possible 
age.  By  active  and  proper  means  commenced  during  the  second  or 
third  years  of  life,  there  is  reason  to  believe  that  results  may  be  obtained 
•  such  as  we  have  at  present  no  idea  of.  At  this  age,  the  first  step  neces- 
sary is  removal  of  the  child  beyond  reach  of  the  influences  (p.  251-276) 


THERAPEUTICS.  355 

of  causation  (when  the  causes  are  miasmatic,  removal  to  another  and 
healthy  locality — not  necessarily  to  a  high  mountain);  and,  in  the  second 
place,  to  see  to  the  proper  regulation  of  the  rearing  of  the  child,  the 
strengthening  of  his  physical  powers,  and  to  a  mild,  gradual,  and 
methodical  excitation  and  elevation  of  his  senses  and  dispositions.  Spe- 
cial cases  (syphilis,  rickets,  etc.)  require  the  treatment  special  to  these 
maladies.  Epileptic  conditions  are,  if  possible,  to  be  treated  according 
to  their  causes,  or,  secondly,  by  atropine  (in  the  epilepsy  of  children  this 
often  produces  most  rapid  results),  oxide  of  zinc,  etc.  But,  in  the 
majority  of  cases,  the  treatment,  especially  that  of  the  asylums,  is  not 
commenced  until  a  much  later  period — at  an  age  when  the  object  would 
rather  be  to  render  the  stunted  remains  of  the  mental  faculties  capable 
of  performing  their  function,  than  to  attempt  to  cure  or  even  improve 
the  morbid  state  of  the  brain.  The  object,  therefore,  is  more  tliat  of 
education.  In  this,  experience  teaches  that  even  at  a  more  advanced  age 
(from  five  to  ten  years)  the  education  depends  altogether  upon  a  healthy 
development  of  the  body.  We  should,  therefore,  with  all  our  energy  try 
to  strengthen  the  constitution,  improve  the  nutrition,  institute  a  feeling 
of  bodily  well-being  and  comfort  (nutritious  food,  exercise  in  the  open 
air,  baths,  cold  sponging,  cod-liver  oil,  iron,  etc.).  It  is  not  so  much  by 
methodical  instruction  (lectures,  reading,  learning,  etc.),  which  has  a 
gently  stimulating  effect  upon  the  brain,  as  by  illustration,  simple  em- 
ployments, the  relating  of  interesting  narratives  which  awaken  the  atten- 
tion— by  well-regulated  practical  exercise  and  games,  which  render  the 
sensorial  impressions  more  correct — that  the  formation  of  proper  though 
simple  ideas  is  to  be  promoted.  Of  what  use  is  it  to  bring  up  learned 
idiots  who  know  the  whole  ABO,  but  stumble  before  every  little 
obstruction  that  comes  in  their  way?  Agricultual  employment  would  be 
well  adapted  for  most  of  the  lighter  cases,  but  it  is  very  difficult  to  obtain 
it.  Music  exerts  a  favorable  influence  upon  many;  constant  repetition  is  a 
means  whereby,  even  in  the  most  serious  cases,  improvement  of  certain 
phases  of  the  mental  life  is  occasionally  obtained;  but  with  these  children 
all  discipline  and  punishment  is  worse  than  useless — any  improvement  is 
only  to  be  obtained  by  kind  and  benevolent  treatment.  The  sociability 
of  the  asylum  is  very  beneficial  and  improving  for  most  of  the  more 
slightly  affected  children, 

I  must  here  restrict  myself  to  these  few  aphorisms;  further  details  will  be 
found  in  the  works  mentioned  in  page  273,  and  in  the  writings  of  Voisin  and 
Eosch,  Erlenmeyer,  Georgens  and  Deii3iardt. 

§  229.  When  hallucinations  are  present,  the  organ  of  sense  to  which 
they  refer  should  be  minutely  examined;  if  necessary,  the  ears  can  be 
syringed,  and  the  attempt  made  to  remove  any  sensorial  irritation  by 
means  of  leeches,  derivatives,  Daturia  stramonium,  etc. 

Should  the  patient  refuse  his  food,  the  mouth  is  the  first  place  to  be 
carefully  examined,  as  refusal  of  food  is  sometimes  caused  by  inflamma- 
tion of  the  buccal  mucous  membrane,  cynanche,  etc.  If  nothing  of  this 
kind  is  discovered,  we  then  attempt  to  turn  the  patient  from  his  resolu- 
tion, not  by  argument,  but  by  placing  before  him  choice  food  when  he  is 
alone  and  silently  taking  it  away  again,  or  by  putting  him  where  he  may 
see  others  eat.  Should  this  not  be  speedily  successful,  we  quietly  pro- 
ceed, after  a  short  exhortation,  to  the  use  of  artificial  alimentation,  by 
forcing  him  to  swallow  food  while  holding  his  nose,  or,  should  he  still 
resist,  by  employing  the  (esophageal  sound.     When  food  has  been  for  a 


356  THERAPEUTICS. 

loug  time  refused,  stimulating  fluids,  such  as  wine,  should  not  be  given 
at  first,  but  mild  substances,  as  milk,  beef-tea,  etc. 

Since  the  publication  of  the  first  edition  of  this  work,  numerous  experiences 
of  the  treatment  of  refusal  of  food  have  been  communicated;  they  all  revert  to 
the  long-tried  mode  of  artificial  alimentation.  It  is  strongly  to  be  recommended 
that  no  time  be  wasted  with  the  employment  of  all  sorts  of  medicaments  (even 
the  preparations  of  copper  have  been  recommended!),  douches,  etc.  Many 
instruments  more  or  less  complicated  have  been  devised  for  artificial  feeding;  as 
Leuret's  double  oesophageal  sound,  of  sheep-gut;  the  instruments  of  Belhomme 
(1850),  Blanchi,  Baillarger,  etc.  A  simple  elastic  sound  introduced  through  the 
nose  is  the  best  of  all:  the  patient  is  held  in  an  oblique  position,  the  head  fixed 
and  a  little  bent  upon  the  chest  while  the  sound  is  being  introduced.  Fluids  are 
injected  through  the  sound;  they  ought  previously  to  be  strained,  always  luke- 
warm—milk, beef-tea  with  eggs,  thin  soup,  etc.— and  always  injected  a  little  at 
a  time,  with  some  fresh  water  between.  Most  of  those  patients  ought  to  lie  in 
bed  all  day,  and  be  kept  warm.  Baths  are  often  very  beneficial.  Nutrient  ene- 
mata  of  preparations  of  beef  and  eggs,  which  have  been  prepared  by  digestion 
with  pepsin  and  a  httle  salt,  or  only  of  strong  beef-tea,  may  frequently  be  used. 
Cases  of  prolonged  alimentation  by  the  sound  are  recorded  (two  years  and  fifty 
days)  in  a  case  of  melanchoha  in  the  Turin  Asylum  communicated  by  Zeluschi; 
Bell  narrates  a  case  in  an  American  asylum  of  two  years'  nourishment.  Should 
we  not  be  able  at  once  to  introduce  the  sound,  the  object  may  be  gained  by  sim- 
ple pouring  through  the  nose;  injecting  is  not  necessary.  A  peculiar  method  has 
been  tried  in  the  asylum  at  Vienna— that  of  opening  the  mouth  by  electricity,  a 
method  which  allows  feeding  with  solid  food.  In  very  excited  patients,  chloro- 
form may  be  tried,  and  food  given  while  the  patient  is  under  its  influence. 

The  habit  of  masturbation  is  very  difficult  radically  to  suppress:  and 
besides,  recovery  scarcely  ever  takes  place  during  its  continuance. 
Mechanical  contrivances  rarely  succeed  in  their  object:  this  is  better 
attained  by  minute  surveillance  of  the  patients,  who  should  never  be  left 
alone;  by  work  or  walking,  even  to  fatigue — light  diet,  cold  bathing,  a 
hard  bed,  and,  in  some  cases,  by  the  utmost  strictness.  The  causes  of 
the  habit  may  require  to  be  treated  by  therapeutical  means;  ascarides  are 
to  be  kept  in  view;  the  iodides,  from  which  some  good  results  have  been 
obtained,  may  be  given  where  the  sexual  irritation  is  produced  by  chronic 
irritation  or  inflammation  of  the  urethra;  lupuline  in  considerable  doses 
(gr.  iv.  three  times  a  day)  and  bromide  of  potassium  may  sometimes  be 
employed. 

Those  patients  who  have  a  tendency  to  suicide  require  to  be  carefully 
watched.  The  inclination  can  rarely  be  subdued  by  medicinal  treatment, 
and  usually  our  means  are  limited  to  constant  personal  surveillance,  the 
removal  of  all  implements,  cords,  etc.;  and  our  attention  ought  to  be 
the  more  unremitting  if  the  patient  exhibits  much  cunning.  Such  patients 
often  accomplish  their  object  in  a  single  unguarded  moment— indeed,  in 
the  very  presence  of  attendants;  for  example,  by  strangulation  in  bed. 
Experience  has  shown  that  mechanical  means  of  restraint  will  not  in  the 
least  diminish  the  tendency  to  suicide,  even  though  it  should  succeed  in 
rendering  its  accomplishment  impossible  for  a  time;  but  sometimes  it 
does  not  even  succeed  in  this.  I  myself  have  seen  a  patient  who  strangled 
himself  when  wearing  a  strait-jacket. 

Before  dangerous,  and  especially  armed  patients,  we  ought  to  show 
undisturbed  self-possession;  there  is  frequently  a  concealed  feeling  of 
anxiety  behind  the  furious  agitation,  and  the  remains  of  a  knowledge  of 
right  from  wrong  which  comes  to  the  aid  of  the  courageous.  They  are 
generally  more  easily  disarmed  by  artifice  tiian  by  force,  and  cases  are  on 
record  where  by  feminine  cunning  the  knife  was  playfully  wrested  from 
the  hand  of  the  madman. 


THERAPEUTICS.  357 

A  young  man  who  had  been  tranquil  for  several  months,  was  suddenly  seized 
with  an  attack  of  mania.  He  ran  to  the  kitchen  and  took  away  an  instrument  used 
for  chopping  vegetables.  He  resisted  those  persons  who  wished  to  lay  hold  of 
him,  sprang  upon  a  table  and  threatened  to  strike  on  the  head  any  one  who  dared 
to  approach.  The  wife  of  Superintendent  Pussin  loudly  called  to  the  people  that 
they  were  preventing  the  patient  from  working  with  her,  requested  him  gently 
to  come  near,  and  showed  him  how  to  use  the  instrument.  At  this  moment  the 
people  laid  hold  of  him  and  took  away  his  weapon.     (Reil,  etc.) 

Several  patients  were  quarreling  in  a  garden:  one  of  them  seized  a  knife  and 
threatened  to  murder  his  comrades.  Lady  ElUs  arrived,  and  said  to  him  that  she 
was  much  surprised  to  see  that  a  man  of  his  understanding  and  strength  could  so 
far  forget  himself  as  to  quarrel  with  a  patient,  and  one  who  was  known  to  have 
been  mad  for  years.  These  words  flattered  his  self-esteem.  "  You  are  right,"  he 
replied,  "I  will  pay  no  more  attention  to  these  men,"  and  became  immediately 
calm.     (Ellis,  etc.) 

A  very  strong,  violent  patient  had  found  opportunity  to  possess  himself  of  au 
iron  bar  three  feet  long,  and  threatened  to  murder  all  who  came  near  him.  Atten- 
dants and  patients  fled,  and  he  was  left  alone  in  the  gallery,  no  one  daring  to 
approach.  After  a  little  while  I  entered  alone:  balancing  the  key  of  the  door  upon 
the  back  of  my  hand,  I  advanced  very  slowly  towards  him,  attentively  observing 
what  excited  his  attention.  He  came  up  to  me,  and  asked  me  what  I  was  doing. 
I  replied  that  I  was  trying  to  balance  the  key,  and  added  that  he  could  not  do  the 
same  with  the  iron  bar.  He  tried  it  in  vain,  stretched  out  his  hand  and  placed 
the  bar  of  iron  upon  it;  I  then  took  it  quietly  from  him  without  any  further  notice. 
Although  it  appeared  to  be  disagreeable  to  him  to  find  himself  disarmed,  he  made 
no  attempt  to  take  back  his  weapon,  and  a  few  minates  afterwards  all  traces  of 
excitement  were  gone.    (Ellis,  'Traite,'  p.  311.) 

§  230.  The  period  of  convalescence  still  requires  much  care  and  super- 
vision. The  convalescent  remains  often  for  a  long  time  in  a  very  weak 
and  irritable  state  of  mind.  The  last  traces  of  the  false  ideas  are  often 
long  in  commencing  to  disappear,  and  it  is  frequently  necessary  to  con- 
tinue the  physical  treatment  for  a  long  time.  The  patient  should  not, 
therefore,  be  allowed  to  leave  the  asylum  till  the  mental  and  bodily  health 
is  as  far  as  possible  consolidated,  generally  not  earlier  than  several  months 
after  the  first  symptoms  of  recovery;  and  the  discharge  should,  as  is  now 
the  practice  in  many  public  asylums,  be  at  first  always  provisional,  so  that 
the  patient,  on  threatened  or  actual  relapse,  may  be  readmitted  into  the 
asylum  without  trouble  or  delay. 

Should  great  relaxation  and  debility  come  on  during  convalescence, 
it  should  not  be  treated  by  stimulating  means;  quietness,  suitable  diet, 
open  air  exercise,  and  gradual  resumption  of  employment,  are  to  be  pro- 
moted. The  patient  is  to  bo  allowed  greater  liberty  and  intercourse  with 
the  world  according  as  the  desire  and  the  capacities  for  it  increase.  He 
should  be  habituated  to  a  suitable  occupation,  and  placed  in  a  pleasant 
neighborhood;  all  that  would  excite  him  should  be  avoided,  or  accom- 
panied by  judicious  encouragement.  lie  should  be  distinctly  told  of  his 
malady.  Courage  and  self-confidence  should  be  raised  within  him, 
through  the  exercise  of  his  faculties,  the  example  of  others,  and  also 
through  the  consolations  of  religion.  Counsel  as  to  future  modes  of  life, 
suitable  employment,  and  to  all  that  can  protect  him  from  a  return  of 
the  disease,  are  now  apj^licable.  In  certain  cases,  amusement,  travel,  or 
residence  at  a  watering  place  might  prove  beneficial;  in  others,  a  speedy 
return  to  the  narrow  sphere  of  their  calling  and  their  family  circle  is  the 
only  means  by  which  recovery  can  be  completed.  Many  go  from  the 
asylum  to  their  homes  more  reasonable  than  they  ever  were  before:  would 
it  were  but  possible  to  keep  those  thankful  and  joyful,  and  frequently 
mentally  strengthened  (recovered),  patients  from  the  influences  of  adverse 
circumstances — the  coldness  of  those  by  whom  they  are  surrounded,  and 
even  from  the  raillery  of  low-thinking  men! 


358  THEKAFEUTICS. 

SECTioisr  V. — Lunatic  Asylums. 

§  231.  In  former  times,  the  leading  object  of  treatment  in  mental 
disease  was  generally  quite  unknown.  With  no  purpose  beyond  the  pre- 
servation of  public  order,  and  the  aversion  of  the  danger  that  might  arise 
to  the  sane  from  the  uncontrolled  roaming  of  such  as  were  mentally  de- 
ranged, some  were  confined  in  hospitals,  others  in  penitentiaries  and 
workhouses,  and  generally  in  the  most  wretched  and  concealed  apart- 
ments. To  treat  them  as  patients  was  a  thing  unthought  of;  the  great 
aim  was  to  render  them  harmless  (a  method  adopted  from  a  mistaken 
notion  of  their  excessive  bodily  strength).  This  was  effected  by  the 
roughest  measures:  the  poor,  unfortunate  creatures,  often  oppressed  with 
chains,  pined  away,  behind  massive  beams  and  iron  bars,  in  wretchedness 
and  filth;  in  the  sufferance  of  tortures  and  lashes  such  as  it  was  their  lot 
to  endure,  the  remaining  traces  of  humanity  could  not  but  disappear. 
Whoever  once  crossed  the  threshold  of  an  asylum  was  considered  lost. 
This  was  the  fate  of  the  insane  in  many  places  until  very  recently.  Even 
so  lately  as  1833-34  in  some  provincial  towns  of  France  they  were  con- 
fined in  prisons;  in  several  English  institutions,  entire  rows  of  them 
might  have  been  seen  m  chains;  and  even  to  the  present  day,  in  a  few 
remote  districts,  their  apartments  are  coarse,  stall-like  inclosures  of  the 
strongest  and  roughest  construction,  before  which  vacant  curiosity  stands 
to  irritate  the  madman  by  a  mockery  of  his  curses.  [Query,  Where? — 
Tkansl.] 

In  the  middle  of  last  century  was  erected  the  first  institution  whose 
avowed  object  was  the  cure  of  insanity — St.  Luke's  in  London,  long  the 
only  example  of  active  humane  feeling  for  the  insane.  This  was  followed 
by  the  erection  of  an  asylum  at  York  for  the  reception  of  Quakers  who 
w"ere  mentally  diseased.  Upon  the  Continent,  Pinel  was  the  first  who 
resolved  to  interest  himself  in  the  condition  of  the  insane.  Impelled  by 
the  great  humanitarian  idea  of  his  time,  he  began  his  efforts  even  during 
the  troublous  times  of  the  Eevolution.  At  first,  not  without  danger  to 
his  own  life,  he  devised,  before  the  very  gates  of  Paris,  in  Bicetre,  his 
great  and  happy  reforms  by  freeing  the  insane  from  their  fetters.'  Pinel'.s 
endeavors  were  an  example,  and  gave  the  impulse  to  a  complete  renova- 
tion of  the  treatment  of  insanity.  The  merit  of  this  reform  in  Germany 
belongs  pre-eminently  to  Langermann,  about  the  beginning  of  the  present 
century.  The  revolution  in  opinions  upon  this  subject  was  even  then  so 
marked,  the  acknowledgment  of  the  curability  and  incurability  of  insanity 

1  Pinel,  in  directing  his  efforts  with  all  his  attention  to  the  amelioration  of  the 
condition  of  the  insane,  first  devoted  them  to  those  who  had  been  confined  at  the 
instigation  of  the  pubUc  authorities.  In  consequence  of  this  interference,  he  was 
stigmatized  as  a  moderate  and  an  aristocrat — names  which  at  that  time  were  al- 
most synonymous  with  sentence  of  death.  Undeterred  by  this,  he  presented 
himself  before  the  Town  Council  of  Paris,  and  with  renewed  energy  solicited 
them  to  sanction  his  reform.  "  Citizen,"  said  Couthon  to  him,  "  I  shall  meet  j^ou 
to-morrow  at  Bicetre,  and  woe  betide  you  if  you  have  deceived  us,  and  if  under 
the  names  of  fools  you  have  concealed  the  enemies  of  the  people! "  Accordingly, 
Couthon  made  his  appearance;  but  the  cries  and  howls  of  the  madmen  when  he 
at  first  attempted  to  interrogate  some  of  them  were  too  much  for  him,  and  he 
said  to  Pinel,  "  O  citizen,  art  thou  thyself  a  fool,  that  thou  wouldst  liberate  such 
animals?  Do  with  them  wliat  thou  wilt,  but  I  am  much  afraid  that  thou  wilt  be- 
come the  victim  of  thy  rashness."  Nevertheless,  the  same  day  Pinel  began  his  task 
and  struck  off  the  chains  from  a  number  of  patients.  See  the  narrative  taken 
from  Pinel's  own  diary,  and  published  by  his  son,  '  Memoires  de  I'Acad.  Roy.  de 
Medecine,'  tome  v.,  Par.,  1836. 


THEKAPEUTICS. 


359 


was  then  so  widespread,  that  he  was  at  once  enabled  practically  and  ener- 
getically to  insist  on  the  erection  of  special  institutions  for  the  cure  of 
insanity;  and  on  their  complete  separation  from  establishments  devoted 
to  incurables.  The  first  German  hospital  in  which  the  new  theory  was 
carried  out  and  practically  accomplished  was  the  Sonnenstein,  in  Saxony, 
under  the  superintendence  of  Pienitz;  side  by  side  with  which  stand,  as 
asylums  for  incurables,  first,  Waldheim,  and,  latterly,  Colditz.  _  These 
first  successful  essays  in  asylum  concerns  were  gradually  followed  in  Ger- 
many either  by  the  new  erection  or  complete  re-modelling  of  the  public 
asylums  in  Schlcswig  (1820),  Sieburg  (1825),  Heidelberg  (1826),  Prague 
(1826),  Hildesheim  (1827),  Leubus  in  Silesia  (1830),  Hall  in  Tyrol  (1830), 
Sachsenberg  in  Mecklenburg-Schwerin  (1830),  Winnenthal  and  Zweifal- 
ten  in  Wiirtemburg  (1834),  Marsberg  in  Westphalia  (1835),  Illenau  in 
Baden  (1842),  Halle  (1844),  Erlangen  (1846),  Eichenberg  in  Nassau 
(1849).  Many  smaller  or  less  known  also  followed  the  example,  and  are 
still  doing  so.  The  erection  of  new  and  well-organized  asylums  is  thus 
constantly  progi-essing,  and  even  these  places  that  were  hitherto  delaying 
as  long  as  possible,  appear  at  last  to  have  made  a  beginning  towards  the 
fulfilment  of  a  requirement  demanded  of  all  civilized  countries.  Among 
those  which  have  been  erected  within  the  last  ten  years  in  Germany,  and 
are  particularly  worthy  of  mention,  are  those  at  Vienna  (1853),  Werneck 
in  Frankonia  (1855),  Klingenmunster  in  the  Pfalz  (1858),  Miinich  (1859). 

With  the  erection  of  such  efficient  institutions,  the  therapeutics  of 
insanity  have  in  most  countries,  within  the  last  forty  years,  made  the 
most  extraordinary  progress.  Thus,  in  Germany,  where  theoretical 
psychology  was  almost  entirely  devoted  to  the  discussion  of  abstruse 
questions  (whether  insanity  is  the  result  of  sinfulness?  whether  in  insanity 
the  body  or  the  soul  is  diseased?  etc.),  practical  efforts  have  almost  in  a 
single  season  been  made  the  chief  regulators  of  asylum  practice,  and  that 
with  the  best  results;  and  in  this  matter,  Jacobi's  exertions  to  introduce 
the  Ensjlish  practice  into  Germany  have  had  an  unprecedented  and  most 
beneficial  effect.  The  literary  treatment  of  these  practical  questions  soon 
became  in  the  highest  degree  irksome,  in  consequence  of  the  extraordi- 
nary pedantry  with  Avhicli  all  the  minutiaa  of  the  asylum  were  canvassed, 
as  if  these  were  primary  questions.  Thus,  the  interest  was  in  a  great 
measure  diverted  from  really  weighty  points  in  psychology  in  order  to 
settle  these  comparative  trifles.  Much,  however,  can  be  excused  at  this 
time,  owing  to  the  novelty  of  the  subject;  and  we  must  always  thankfully 
acknowledge  the  exertions  by  which,  in  so  short  a  time,  results  so  remark- 
able were  effected.  Even  this  paltry,  insipid  devotion  to  trifles  appears 
to  do  good,  in  spite  of  the  bombast  with  which  they  have  been  recently 
asserted  and  oracularly  promulgated.  Notwithstanding,  in  Germany, 
till  within  a  short  time  ago,  there  was,  and  even  yet  there  is,  much  re- 
maining to  be  done.  In  proof  of  this  I  shall  only  cite  one  example.  An 
account  of  an  excursion  by  Willing  in  tlie  year  1856  contains  the  follow- 
ing ('Ztschr.  f.  Psych.,'  xiii.,  p.  84):—"  In  the  noisy  patients  are 

confined  in  cells;  the  cells  for  the  men  and  women  adjoin  one  another, 
and  only  through  a  grating  can  a  patient  be  communicated  with.  The 
quiet  patients  employ  themselves,  the  men  and  women  associating  to- 
gether. " 

§  232.  From  the  commencement  of  the  reforms,  the  conviction 
gained  root,  especially  in  Germany,  that  the  first  condition  of  success  in 
treatment  was  the  separation  of  the  curable  from  the  incurable  insane. 
Indeed,  the  mixing  of  the  recent  cases  with  incurables,  with  epileptics 


360  THERAPEUTICS. 

and  cretins,  proved  perfectly  ruinous:  the  rery  sight  of  these  creatures, 
so  demoralized,  exerted  an  influence  upon  the  former  in  the  highest  de- 
gree injurious.  Besides,  the  two  classes  of  insane  require  for  their  treat- 
ment and  protection  arrangements  differing  in  many  particulars,  and, 
naturally,  the  space  of  the  asylum  would  by  such  mingling  become  so 
much  occupied  with  incurables,  that  it  could  no  longer  receive  recent 
aud  curable  cases.  Whilst  in  certain  foreign  asylums — as,  for  example, 
Salpetriere — different  departments  of  the  same  institution  have  for  a  long 
time  been  set  apart,  the  one  for  cases  requiring  active  treatment,  and  the 
other  for  such  as  had  become  quite  chronic;  in  Germany,  and  occasion- 
ally in  England,  another  principle  has  been  adopted — the  erection  of 
special  institutions,  quite  separate,  for  curable  cases  and  for  incurables 
(Sonnenstein,  Siegburg,  Leubus,  Winnenthal,  etc.).  Various  reasons  led 
to  this  arrangement  of  special  hospitals  for  treatment  and  asylums  for 
incurables.  It  was  the  wish  to  bring  into  practice  the  new  attempts  at 
reform  in  asylum  concerns,  which  were  associated  with  much  expense,  at 
first  only  for  those  of  the  insane  who  were  considered  curable;  new  asy- 
lums were  therefore  built  for  those,  while  the  old  institutions,  which  had 
been  found  quite  inefficient  for  the  carrying  out  of  attempts  at  cure, 
were,  with  a  few  alterations,  converted  into  asylums  for  incurables.  It 
was  soon  understood  that  the  organization  of  asylums  for  incurables 
must,  in  many  points,  be  essentially  different  from  hospitals  for  the 
treatment  of  recent  cases,  inasmuch  as  we  have  to  consider  that  in  the 
former  case  nearly  all  have  to  remain  during  their  entire  subsequent 
lives,  while  in  the  latter  their  residence  is  but  temporary;  and,  further,  it 
was  a  decisive  blow  to  strong  wide-spread  prejudice  when,  long  before 
public  acknowledgment  of  the  curability  of  insanity,  special  hospitals  were 
erected  where  an  average  proportion  of  rapid  recoveries  were  effected. 

There  was  every  reason  to  be  satisfied  with  the  general  result  of  this 
system  where  the  number  of  inmates  m  the  institution  for  treatment  and 
in  the  asylum  for  chronic  cases  were  suitably  proportioned,  where  each 
enjoyed  an  equal  amount  of  the  fostering  care  of  the  State,  and  where 
there  existed  for  both  a  certain  unity  in  the  higher  superintendence.  So 
far  as  we  are  aware,  it  was  not  on  account  of  any  deficiency  in  this  sys- 
■  tern  in  relation  to  the  treatment  and  guardianship  of  the  insane  which 
led,  at  a  later  date,  to  its  expediency  being  called  in  question,  and  the 
curable  and  the  incurable  being  again  united  under  one  roof.  External 
motives,  the  results  of  theoretical  advocacy  and  numerous  practical  at- 
tempts appear  to  us  to  have  effected  this  reunion. 

§  233.  When,  about  twenty  years  ago,  it  began  to  be  considered  a 
requisite  that  asylums  should  be  new  and  specially  erected  institutions, 
in  many  countries  men  hesitated  at  a  prospect  so  expensive  as  the  erection 
of  several  large  establishments,  with  their  complicated  arrangements  and 
increased  medical  superintendence.  They  could  not,  however,  return  to 
the  former  system  of  mingling  all  the  insane,  the  alienists  insisting  on 
the  complete  separation  of  the  curables  from  the  incurables.  So  the  plan 
was  formed,  and  in  several  cases  carried  out,  of  constructing  two  separate 
establishments,  each  complete  in  itself,  but  situated  within  the  same 
grounds,  under  the  same  medical  superintendence,  and  having  in  com- 
mon many  economical  arrangements  (chapel,  storehouses,  kitchen,  baths, 
etc.).  Thus  the  great  so-called  "relativ  verbundenen"  asylum  system  is 
not,  as  they  would  have  us  believe  in  Berlin,  the  project  of  Hegel's  logic, 
though  certainly  he  was  a  strong  advocate  of  it,  and  that  in  a  manner 
worthy  of  consideration. 


THERAPEUTICS.  361 

It  might  be  said  in  favor  of  this  system,  that  where  new  buildings 
have  to  be  erected,  it  is  less  costly,  because,  as  remarked  above,  many 
buildings  and  arrangements  being  common,  one  set  only  is  required  for 
both  institutions;  many  patients  being  united  under  one  management, 
fewer  officials  are  required;  and  as  such  an  asylum  can  sooner  maintain 
itself  by  the  produce  of  its  own  labor — which  is  chiefly  from  the  inmates 
of  the  incurable  institution — it  is  less  expensive  to  the  State.  As  further 
reasons  for  such  union,  it  has  been  urged  that  the  boundary  between 
curability  and  incurability  is  in  the  highest  degree  fluctuating  and 
uncertain;  that  in  "relativ  verbundenen"  institutions  the  patient  is 
observed  by  the  same  physician  in  every  stage  of  his  disease  to  its  termi- 
nation; that  the  admission  of  patients,  not  being  delayed  by  discussion 
about  the  proper  institution — which  must  depend  upon  the  prognosis — is 
facilitated;  that  such  institutions  admit  of  an  easy  survey  of  the  whole 
number  of  lunatics  in  a  land  or  in  a  province;  that  the  inmates  of  an 
asylum  for  incurables  can,  when  necessary,  be  very  easily  remitted  to  the 
hospital  for  treatment;  whereas,  in  the  other  system,  the  transference  of 
patients  from  a  curable  to  a  chronic  asylum  is  a  process  not  only  dilatory 
and  expensive,  but  also  very  hard  and  disheartening  to  the  patient  and 
his  friends,  and  a  return  to  the  hospital  upon  the  reappearance  of  favor- 
able symptoms  is  then  almost  impossible. 

But,  on  the  other  hand,  it  may  be  argued  that  the  chronic  asylum 
should  not  be  a  place  whose  portal  bears  the  inscription  "Lasciate  ogni 
speranza."  Though  solely  fitted  up  for  the  reception  of  old  chronic 
cases,  yet  the  means  of  recovery  ought  still  to  be  present  in  the  person  of 
the  physician,  and  in  the  external  relations  of  the  patient,  which  occasion- 
ally, though  not  frequently,  afford  returning  hopes  of  recovery.  Indeed, 
in  the  chronic  asylum  sometimes  patients  do  recover,'  and  that  without 
casting  any  slur  upon  the  institution  for  treatment,  which,  in  the  trans- 
ference of  such  a  patient,  would  only  say  that  nothing  more  can  there  be 
done,  but  that,  however,  other  and  quite  new  relations  might  still  prove 
beneficial  to  him.  Zeller,  for  instance,  lays  great  stress  upon  the  fact 
that  removal  to  another  institution*  proves  to  many  patients  of  no  small 
value,  and  adduces  as  important  arguments  against  the  union  of  the 
institution  for  cure  with  that  for  mere  guardianship,  the  want  of  efficient 
superintendence  and  of  treatment  of  individual  cases  Avhere  there  are  so 
many  patients  under  the  care  of  one  physician;  the  overloading  of  the 
medical  superintendents  with  a  mass  of  official  business  of  no  service  to 
the  patients;  the  great  confusion  which  must  result  from  a  system  so 
complicated  and  requiring  so  many  assistants;  the  danger  of  the  physi- 
cians neglecting  the  incurables,  owing  to  the  greater  attraction  offered  by 
the  curable  cases,  they  being  so  much  richer  in  results;  finally,  the  evil 
influence  which  the  sight  of  so  many  lost  and  hopeless  lunatics — nay, 
even  the  very  knowledge  of  the  proximity  of  so  many  who  are  incurable 
— has  upon  the  recently  admitted  cases. 

The  system  of  relatively  connected  ('^relativ  verbundenen")  recent 

'  According  to  Focke,  the  recoveries  in  incurable  asylums  are  at  the  rate  of  from 
3  to  6  per  cent.  In  Pforzheim  there  recovered  from  secondary  dementia  from  4 
to  6  per  cent. 

^  See  the  interesting  communication  by  Trelat  regarding  the  transference  of  a 
great  number  of  insane  from  the  overcrowded  asylums  of  Paris  to  several,  in 
many  cases  far-distant,  provincial  institutions,  '  Annal.  Med.  Psychol.,'  tome  iv., 
1844,  pp.  230,  366.  The  advantage  of  transference  to  another  institution  has 
recently  been  learned  in  England;  'Ztschr.  f.  Psych.,'  xv.,  1858,  pp.  114,  147. 


562  THERAPEUTICS. 


and  chronic  asylums,  as  advanced  by  Damerow,  lias  been  fully  and  prac- 
tically carried  out  only  in  a  very  few  places  (Illenau  and  Halle);  and  in 
these,  indeed,  the  separation  of  the  hospital  from  the  asylum  has  always 
been  more  fanciful  than  real,  and  may  nowadays  be  regarded  as  com- 
pletely abandoned.  In  this  system  there  is,  at  all  events,  one  other 
institution  required,  to  which,  out  of  the  relatively  connected  ("relativ 
yerbundenen")  chronic  asylum — if  this  is  not  to  become  of  stupendous 
proportions — a  regular  draft  can  again  take  place  of  all  such  as  are  abso- 
lutely hopeless,  those  afflicted  with  other  diseases — in  short,  the  Avorst  of 
the  incurables  (idiots,  epileptics,  etc.,  etc.).  But  if  only  a  certain  num- 
ber of  incurables,  and  selected  from  amongst  the  best  of  that  class  { i.  e. ,  the 
quiet,  and  those  still  capable  of  leading  a  rational  life)  remain  in  the 
'•'relativ  verbundenen"  cure  institution,  there  will  not  be  required  for 
these  a  perfectly  distinct  set  of  buildings,  and  a  special  chronic  asylum 
relatively  connected  with  the  hospital  for  treatment.  These  incurables 
may,  almost  without  harm,  dwell  amongst  the  recent  and  curable  cases; 
nay,  many  alienists  recognize  in  the  presence  of  a  stock  of  such  long- 
disciplined  incurable  inmates  a  beneficial  and  essentially  curative  element 
for  the  newly  admitted  patients.  So  that  recently,  in  a  new  asylum 
which  would  have  presented  unusual  advantages  for  a  ''relativ  verbun- 
denen" cure  and  chronic  institution,  this  system  has  been  foregone,'  and 
in  the  more  lately  built  asylums  in  Germany,  and  in  plans  for  such,  the 
system  of  mingling  the  incurable  (of  the  better  sort)  with  the  curable  has 
been  again  adopted  (as  is  moreover  also  the  case  in  by  far  the  greater 
number  of  asylums  both  in  England  and  France). 

But  that  is  not  to  say  that  we  have  reverted  to  the  old  system  of  mix- 
ing all  the  insane  indiscriminately  together;  but  the  principle  of  division, 
founded  upon  curability — a  principle  Avhich  was  founded  upon  motives 
the  most  earnest— and  which,  at  least  in  Germany,  has  long  served  as  a 
guide  for  the  variety  of  institution,  has  been  abandoned.     It  appears  to 
me  that  in  the  special  cure  institutions,  that  nucleus  of  patients  habitu- 
ated to  an  asylum,  which  appears  so  desirable,  forms  everywhere  of  itself, 
in  spite  of  the  destination  of  the  cure  institution,  and  entirely  without 
the  connivance  of  the  physician;  for  it  is  well  known  that  nothing  is 
more  difficult  to  maintain'in  a  pure  hospital  than  a  regular  and  prompt 
dismissal  of  all  the  incurable  patients,  and  always  a  numberof  these  in- 
sane remain  through  entire  years,  even  although  their  insanity  is  known 
to  be  incurable.     Whether,  then,  is  it  better  to  erect  asylums  which  shall 
receive  curable  lunatics  mingled  with  a  certain  select  number  of  incura- 
bles, or  such  as  are  destined  entirely  for  curable  (recent)  cases,  and  from 
which  all  who  become  incurable  are  again  ejected?     This  is  a  question 
which  cannot  be  answered  in  a  general  way.     The  solution  of  this,  like 
so  many  practical  questions  regarding  asylum  concerns,  depends  very 
much  upon  the  population  of  the  country,  upon  the  number  of  lunatics 
already  in  asylums,  upon  the  possibility  of  making  use  of  the  existing 
buildings,  upon  the  pecuniary  resources  at  one's  disposal,  upon  the  spe- 
cial aims  which  it  is  intended  to  combine  with  their  erection  {e.  g.,  clini- 
cal instructions),  and  most  of  all  depends,  in  the  end,  upon  the  style  of 
execution,  and  the  spirit  which  is  imparted  to  the  whole  by  those  charged 
with  the  direction  of  such  matters.     At  all  events,  it  seems  to  me  as 


1  Gudden,  '  Ztschr.  f.  Psych.,'  xvi.,  1859,  p.  628. 


THERAPEUTICS.  363 

premature  completely  to  renounce  the  system  of  special  cure  institutions.' 
If,  liowever,  we  accept  this  system  of  two  relatively  connected  lunatic 
asylums,  the  chronic  asylum  must  be  capable  of  containing  at  least  three 
times  the  number  of  inmates  of  the  other  (3-400  :  100).  The  chronic 
asylum  can  and  must  be  large;  the  cure  institution  must  be  able  promptly 
to  dismiss  all  recognized  as  incurable.  When  these  conditions  are  fulfilled, 
when  the  cure  institution  contains  such  patients  only  as  are  undergoing 
active  treatment,  then  their  number  ought  never  to  exceed  one  hundred; 
for  even  with  this  number  it  is  almost  impossible  for  one  physician  to 
examine  minutely  into,  and  actively  to  treat,  each  individual  case. 

Whatever  system  be  adopted  for  the  regulation  of  asylum  matters  in 
a  country,  the  special  guardianship  of  the  State  ought,  at  all  events, 
only  to  be  extended  to  a  certain  portion  of  the  insane.  The  overcrowd- 
ing, of  which  all  lunatic  asylums  at  present  complain,  the  pressure  upon 
them,  and  which  is  always  bringing  discredit  upon  the  calculations  upon 
which  they  are  constructed,  must  somewhere  find  a  limit.  This  is 
possible.  In  the  first  place  it  is,  of  course,  necessary  that  those  calcula- 
tions be  correct  (based  upon  an  exact  calculation  of  the  number  of  insane 
in  a  country,  and  it  can  be  assumed  that,  at  the  utmost,  half  of  them 
require  the  care  of  an  asylum),  but  in  that  case  there  should  be  received 
into  the  chronic  asylum  only  the  dangerous  patients,  or  the  incurables 
who  cannot  be  taken  care  of  in  families  or  in  parishes  (not,  however,  the 
absolutely  inoffensive  or  simply  troublesome),  and  no  concession  ought  to 
be  made  to  families  and  parishes  for  supporting  the  harmless  incurables; 
it  is  their  duty  to  take  care  of  them,  and  the  State  ought  to  see  that  this 
duty  be  both  satisfactorily  and  humanely  performed.  It  is  self-evident 
that  the  State  asylums  for  incurables  ought  only  to  be  made  use  of  by 
the  poor.  As  to  the  curable  patients,  it  is  the  duty  of  the  State  to  see 
that  the  necessitous  are  treated  as  such  in  the  asylums  devoted  to  the 
purpose  of  treatment;  but  whether  it  should  also  see  to  those  of  the 
insane  who,  by  their  own  private  means,  are  able  to  enjoy  all  the  de- 
sirable advantages  found  in  good  private  asylums,  is  still  an  open 
question.  Were  this  question  answered  in  the  negative,  a  great 
simplification  and  reduction  would  take  place  in  all  that  concerns  public 
asylums,  and  in  all  large  countries  the  erection  of  pauper  asylums  of  very 
simple  organization,  for  treatment  and  for  care,  would  certainly  be  a 
great  advantage.  But,  of  course,  in  the  present  condition  of  affairs,  it  is 
not  yet  possible  to  effect  a  conversion  of  all  the  public  lunatic  asylums 
into  pauper  lunatic  asylums. 

§  234.  If  we  proceed  now  to  examine  the  general  requisites  for  a 
public  lunatic  asylum,  we  may  place  in  the  foremost  rank  facility  of 
access  to  the  patients,  and  the  capability  of  constantly  receiving  fresh 
cases.  We  shall  attain  these  objects  partly  by  regulations  of  the  medical 
23olice,    and   partly   by   dispensing  with   all   useless    and   time-wasting 

'  Roller  ('Ztschr.  f.  Psychol.,'  x.,  p.  397)  at  that  time  considered  the  question 
regarding  the  best  system  for  quite  distinct,  in  the  sense  of  • "  relativ  verbun- 
denen,"  cure  and  chronic  asylums,  and  imagines  that  no  man  would  now  think 
of  erecting  completely  separated  asylums  for  recent  cases.  According  to  a  new 
order  of  lunatic-asylum  arrangements,  it  was  no  longer  proposed  to  erect  in  the 
province  of  Silesia  a  "relativ  verbundenen"  institution,  but  to  hare  one  cure- 
institution  where  patients  should  undergo  treatment  for  a  certain  fixed  period 
(one  year),  two  cure-institutions  where  patients  should  reside  for  an  indefinite 
time,  and  one  chronic  institution  (ibid.,  1855,  p.  438).  In  1858  there  was  a  prize 
offered  in  Germany  for  the  best  plan  of  a  lunatic  asylum  for  purely  recent  cases 
<Heilanstalt)  capable  of  containing  from  150  to  300  patients. 


364:  THERAPEUTICS. 

formalities,  by  diminishing  the  cost  of  maintenance  or  gratuitously  sup- 
porting patients  of  the  poorer  classes,  and  by  inspiring  the  public  with 
confidence  in  asylums  generally;  and  further,  as  a  result  from  this,  in  all 
large  countries  the  asylums  would  be  more  distributed  in  different 
districts.  Asylums,  too,  ought  to  recommend  themselves  by  their 
excellent  organization  and  by  the  spirit  which  pervades  them;  and  not 
only  ought  this  organization,  and  this  spirit,  to  be  in  conformity  with 
the  ideas  of  humanity  in  our  own  epoch,  but  they  must  also  be — and  this 
is  truly  a  fundamental  requisite — out-and-out  medical. 

Every  asylum  is  nothing  more  than  an  hospital  for  those  affected 
with  disease  of  the  brain.  All  of  them,  and  especially  those  whose  object 
is  the  cure  of  the  patients,  must  all  throughout  present  the  character  of 
an  hospital,  not  of  a  reformatory,  a  manufactory,  or  a  prison.  It  may 
be  here  stated,  at  the  same  time,  that  everything  in  connection  with  the 
asylum  must  be  under  medical  superintendence,  that  its  management  must 
be  in  the  hands  of  the  chief  physician,  who  should  have,  with  a  certain 
freedom  from  restriction,  command  of  all  extraneous  aids  for  the  benefit 
of  the  whole  institution;  but  the  physician  to  an  asylum  must  be  a 
thorough  physician,  and  not  simply  a  manager,  who,  though  possessing  a 
knowledge  of  medicine  to  some  extent,  is  yet  at  every  examination  of  his 
patients  obliged  to  call  in  the  assistance  of  a  regular  practitioner. 

The  peculiarity  of  the  diseases  treated  in  an  asylum  require  the 
physician  to  have  at  command,  not  only  all  the  usual  medical  appliances 
(pharmaceutic  baths,  etc.),  but,  in  addition  to  these,  every  arrange- 
ment tending  to  prevent  patients  inflicting  injury  on  themselves  or 
others,  and  to  have  them  always  amenable  to  medical  treatment.  In  the 
same  w^ay  must  be  provided  whatever  else  is  necessary  to  their  main- 
tenance, exercise  in  the  open  air,  labor,  recreation,  and  amusement. 
Thus,  institutions  of  this  kind  must  be  furnished  not  only  with  a  staff  of 
servants  for  superintending  and  waiting  upon  patients,  and  extent  of 
accommodation  necessary  for  individuals  who  require  isolation  (in 
addition  to  the  ordinary  means  of  restraint),  but  it  must  also  be  furnished 
with  plots  of  ground  for  the  employment  of  the  patients  in  field  labor, 
gardens  and  pleasure  grounds  for  walking,  materials  for  working,  and 
every  possible  means  of  amusement. 

A  requisite  even  more  essential  in  the  arrangement  of  an  asylum  is 
the  appropriate  separation  of  patients  from  one  another;  in  the  first  place 
according  to  sex  (this  is  usually  done  by  apportioning  them  to  separate 
wings  of  the  establishment);  then  according  to  the  form  of  madness,  yet 
not  strictly  according  to  nosological  classification,  but  rather  by  the 
symptoms  of  the  malady  {i.  e.,  whether  quiet  or  more  turbulent);  and 
lastly,  among  the  quietly  disposed  who  Jive  together  according  to  their 
station  in  life  and  their  intellectual  cultivation  (of  course  in  the  case  of 
the  secluded  such  distinctions  are  needless).  For  the  purpose  of  thus 
separating  the  patients,  the  nosological  form  cannot  be  accepted  as  a  rule, 
especially  because  the  cases  usually  present  such  mixed  forms  and  so  mul- 
tifarious transitions;  because  it  would  even  be  dangerous  in  some  cases 
(e.  g .,  in  jjatients  with  suicidal  tendencies)  to  permit  them  to  live  together 
and  to  have  much  intercourse;  and  lastly,  because  the  aj^parently  quiet 
melancholic  maniacs  and  dements  could  not,  as  proved  by  iiniversal  expe- 
rience, well  live  together  w'ithout  an  equal  amount  of  trouble  and  preju- 
dicial results  ensuing:  the  dements,  especially  the  paralytics,  must  be 
entirely  separated  and  confined  to  apartments  expressly  devoted  to  them. 
In  the  separation  of  patients  according  to  their  outward  demeanor,  one 


THERAPEUTICS.  365 

must  be  cautious,  in  so  doing,  not  to  carry  it  to  such  an  extent  as  to 
subdivide  the  service  too  much,  and  thereby  augment  the  requisite 
amount  of  superintendence.  From  four  to  five  divisions  are  needed,  both 
on  the  male  and  female  sides:  one  for  individuals  who  must  be  secluded 
{e.  g.,  the  dehrious,  noisy,  and  most  unruly),  though  this,  of  course, 
should  be  limited  to  the  shortest  possible  time,  a  second  (especially  in  the 
chronic  asylum)  for  the  paralytic,  epileptic,  and  arrant  idiots;  two  for 
quiet  patients  (one  for  those  of  the  higher  class,  another  for  those  in  the 
humbler  stations  of  life);  fifth,  divisions  or  detached  dwellings  for  con- 
valescent or  other  patients  for  whom  it  may  be  considered  beneficial  for  a 
longer  time  to  live  more  retired,  and  in  perfect  quiet.  In  many  institu- 
tions yet  another  division  is  kept  for  the  bedridden,  and  a  perfectly 
detached  building  for  convalescents.  This  last  has  proved  not  so  expe- 
dient. 

In  several  institutions  situated  in  large  towns,  a  division  is  reserved 
for  insane  persons  who  have  committed  some  crime.  In  Bicetre  there  is 
a  division  for  this  purpose,  but  it  is  of  a  dirty  menagery-like  character. 
Dundrum  in  Dublin  is  a  well-conducted  institution,  especially  set  apart 
for  the  reception  of  such  individuals,  and  capable  of  accommodating 
iibout  a  hundred  j^atients.  In  Konigsberg,  also,  there  is  an  institution  of 
this  description,  and  in  America  several  have  lately  been  opened.  The 
greater  number  of  insane  criminals  would,  however,  as  Delbriick  has 
l^ointed  out,  be  much  better  if  left  in  a  penitentiary  than  removed  to  an 
asylum. 

The  chief  literature  on  the  subject  of  lunatic  asylums  may  be  here  re- 
ferred to:  Zeller,  'Art.  Irrenanstalten  in  Ersch  und  Griiber's  Encyclo- 
])adie;'  Damerow,  'Ueber  die  relative  Verbindung  der  Irren-Heil- und 
Pflegeanstalten,'  Leipzig,  1840;  Parchai^pe,  '  Des  Principes  a  suivre,'  etc., 
Paris,  1853;  Guislain,  '  Le9.  oral.,'  iii. 

§  235.  In  different  countries  Avhere  the  subject  of  insanity  has  re- 
ceived attention,  it  has  been  attempted  to  meet  these  requirements  by 
widely  different  architectural  arrangements.  While  the  English  institu- 
tions in  general  present  a  most  imposing  appearance  by  their  massive  and 
elegant  exterior,  possess  the  greatest  completeness  in  the  interior  as  re- 
gards convenience  of  space  and  all  domestic  arrangements  (as  heating, 
lighting,  cleaning,  working  arrangements,  etc.),  and,  combined  Avith 
great  comfort,  a  certain  regularity  of  routine  that  corresponds  well  with 
the  almost  mechanical  nature  of  the  superintendence  and  treatment,  the 
French  asylums,  on  the  other  hand,  are  constructed  on  quite  a  different 
principle,  especially  those  formed  on  Esquirol's  plans.  They  consist  of  a 
series  of  square  houses,  widely  apart,  of  merely  a  ground-floor  containing 
a  number  of  single  cells  or  rooms,  a  common  conversation-room,  work- 
room, etc.,  with  a  colonnade  around,  and  inclosed  in  the  centre  a  plot  of 
grass.  Several  parallel  rows  of  such  single-storied  squares  are  connected 
together  by  those  colonnades,  including  the  storehouses,  work-room, 
chapel,  bathing-houses,  etc.  This  mass  of  distinct  buildings,  which  oc- 
cupies an  immense  area,  is  not  only  more  costly  to  erect,  but  renders  the 
oversight  more  difficult,  and  affords  fewer  facilities  of  visiting  the  more 
distant  parts  of  the  institution  and  of  general  superintendence. 

On  this  account,  up  to  the  period  when,  by  the  introduction  of  labor 
and  instruction,  quite  different  principles  were  followed  in  the  construc- 
tion and  arrangement  of  French  asylums,  these  institutions  were  dis- 
tinguished by  a  want  of  restraint,  the  uncontrolled  roaming  about,  and 
unruly  character  of  the  patients.     In  the  construction  of  the  most  modern 


36G  THERAPEUTICS. 

institutions  in  France,  the  ideas  of  Esquirol  seem  to  liave  been  consider- 
ably deviated  from. 

In  Germany  there  has  been  an  attempt  to  combine  the  good  qualities 
of  both  systems,'  although,  upon  the  whole,  the  German  institutions  ap- 
jn-oach  nearer  in  their  construction  to  the  English  asylums  than  to  those 
formed  on  the  plans  of  Esquirol.  The  newer  institutions  are  usually  so 
arranged,  that  in  one,  or  several,  central  buildings  of  two  or  three  stories 
in  height,  the  common  rooms,  the  office,  the  chapel,  the  kitchen,  the 
washing-houses,  the  store-rooms,  the  rooms  of  the  officials,  are  all  to- 
gether. From  each  side  of  these  one,  or,  in  "  relativ  yerbundenen  "  insti- 
tutions, two  double-storied  wide  wings  extend,  either  in  direct  communi- 
cation or  detached.  In  these  are  the  different  divisions  for  convalescents, 
boarders,  quiet  patients  of  middle  and  lower  rank  in  life,  together  with 
attendants'  accommodation,  baths,  etc.  As  a  completion  to  the  whole, 
are  small,  single-storied  buildings,  as  far  as  possible  removed  from  the 
centre,  which  contain  the  cells  for  unruly  patients,  especially  those  re- 
quiring isolation.  Each  division  of  the  house  must  have  its  own  garden 
and  pleasure-grounds  for  its  inmates;  all  the  stairs,  windows,  and  doors 
must  be  seen  to,  that  they  are  not  only  of  sufficient  strength,  but  also 
that  they  are  of  the  simplest  possible  mechanism,  and  a  sufficient 
guarantee  for  the  security  of  the  patients;  the  internal  fittings  of  the 
dwelling  and  sleeping  apartments  in  the  division  for  the  noisy  and 
maniacal  must  be  of  the  simplest  description;  it  must  also  be  immovable, 
and  in  the  other  parts  of  the  institution  simpler  or  more  elegant,  accord- 
ing to  the  station  and  requirements  of  the  patients. 

A  leading  principle  in  the  erection  and  whole  internal  arrangements, 
Avhicli  has  certainly  been  too  often  overlooked,  is  that  all  the  household 
arrangements  of  an  asylum  should,  so  far  as  is  consistent  with  its  peculiar 
design,  resemble  those  of  a  large  private  dwelling-house — that  they  should 
differ  as  little  as  possible  from  the  houses  and  furnishings  of  the  sane. 
On  this  princii)le  all  plans  are  objectionable  which,  b}^  attractive  peculi- 
arities of  architecture,  such  as  steeples,  turrets,  etc.,  insinuate,  even  by 
their  external  appearance,  that  they  are  intended  for  some  peculiar  pur- 
pose. All  prison-like  cells  on  the  one  hand,  and  on  the  other  all  undue 
magnificence  in  lofty  halls,  colonnades,  etc.,  must,  on  the  same  principle, 
be  avoided.  It  should  throughout  have  the  appearance  of  a  medical  in- 
stitution, whose  express  aim  is  the  restoration  of  health;  it  should  convey 
the  idea  of  ease,  comfort,  stability;  it  should  also  be  cheerful  and  pleasant, 
with  a  scrupulous  regard  to  cleanliness,  which  in  such  institutions  should 
be  always  assiduously  and  perseveringly  insisted  on. 

The  institution  must,  moreover,  be  situated  in  a  healthy  locality,  and, 
where  it  is  possible,  in  a  neighborhood  rich  in  natural  beauties.  It  may 
be  well  to  have  it  in  the  vicinity  of  a  small  town,  where  the  necessary 
provisions  may  be  had,  and  intercourse  conveniently  maintained  with  the 
inhabitants.  It  is  needful  also  to  have  asylums  in  proximity  to  large 
cities.  Institutions  so  situated  have  the  advantage  of  a  constant  supply 
of  new  cases.  Under  no  circumstances,  however,  should  an  asylum  be 
built  within  the  precincts  of  a  city.  It  should  be  surrounded  by  a  piece 
of  ground,  its  own  property,  inclosed  all  round  by  a  wall.     It  is  of  great 


'  Holland  has,  in  its  distinguished  Meer-en-Berg,  produced  a  model  institution 
by  combining  in  a  certain  degree  the  advantages  of  all  the  systems:  specially  as 
in  that  country  Schroeder  van  der  Kolk  has  directed  all  the  matters  connected 
with  the  insane  in  such  a  pattern  manner. 


THERAPEUTICS. 


367 


advantage  to  have  the  ground-floor  raised  above  the  level  of  the  soil. 
Where  practicable,  it  should  be  built  near  a  flowing  stream,  in  order  that 
the  bathing  and  washing  establishments  may  possess  an  abundant  supjily 
of  fresh  water,  and  for  the  purpose  of  out-of-door  bathing.  The  grounds 
should  be  extensive  and  agreeable,  with  gymnasium,  skittle-gi-ound,  play- 
ground, etc. 

Where  there  are  special  chronic  asylums  (Pflegeanstalten),  much 
larger  workrooms  will  be  required,  in  which  the  patients — especially 
during  the  winter  season — may  employ  themselves,  and  where  many 
things  necessary  for  the  institution  may  be  made.  Asylums  of  this  kind 
must  also  have  the  usual  divisions  for  the  unruly,  the  quiet,  the  well- 
conducted  of  all  grades;  however,  they  may  be  much  sirnpler,  and  it  is 
expedient  to  erect  a  greater  number  of  single-storied  dwellings  on  account 
of  the  large  number  of  dirty  patients  and  of  paralytics. 

Of  institutions  for  the  reception  of  idiots,  a  twofold  division  can  also 
be  made:  of  those  whose  object  is  the  cure  or  improvement  of  the  inmates, 
and  of  those  devoted  merely  to  their  confinement.  Since  the  undertak- 
ing of  Gruggenbiihl  on  the  Abendberg  (1841)  these  first  have  attracted 
great  interest,  and  in  them  numerous  experiments  have  been  made,  but, 
from  the  very  nature  of  the  case,  their  benefits  can  extend  only  to 
children,  and  thus  they  partake  more  of  the  nature  of  training  institu- 
tions than  of  hospitals.  Ferrus  Sequin  and  Voisin  during  the  last  thirty 
years  have  given  a  great  impulse  to  the  efforts  for  the  training  and  cure 
of  idiots;  and  even  so  early  as  1835  a  clergyman  of  Wiirtemberg  (Halden- 
wang  in  Wildberg)  had  a  small  institution  erected  for  the  training  of  idi- 
otic children.  After  the  plan  of  that  at  Abendberg,  the  following  insti- 
tutions were  founded:  that  at  Mariaberg  (founded  by  Rosch,  1847), 
Winterbach  (likewise  in  Wiirtemburg,  1852),  Ecksbergm  Bavaria  (1852), 
Hubertusburg  in  Saxony  (a  Government  institution,  1852),  two  in  Berlin 
(one  in  Liesing  near  Vienna,  one  in  Bendorf  in  Coblenz),  one  large  idiot 
school  in  the  Hague  (1855),  and  many  still  smaller  or  less  known  houses;, 
but  all  of  these  are  far  surpassed  by  the  magnificent  institution  of  Earls- 
wood,  in  the  vicinity  of  London  (1857). 

It  does  not  fall  within  the  province  of  this  book  to  treat  in  detail  how 
such  institutions  should  be  furnished  and  organized  so  as  to  accomplish 
their  special  ends  (p.  364);  but,  in  general,  that  may  very  easily  be  de- 
duced from  the  propositions  already  laid  down  when  discussing  the  treat- 
ment of  idiots.  Concerning  the  more  modern  idiot  asylums,  see  Theile 
(loc.  cit.,  p.  105). 

§  236.  At  the  head  of  the  per&onnel  of  the  lunatic  asylum,  subject  to 
the  directing  authorities  of  the  State,  stands  the  superintending  jihysi- 
cian,  by  whose  character,  as  a  man  and  as  a  scholar,  the  pervading  influ- 
ence in  the  institution  in  a  great  measure  depends.  Side  by  side  with 
the  grand  essential  of  a  thorough  acquaintance  with  medicine  (and,  in 
institutions  specially  devoted  to  the  cure  of  insanity,  a  particular  knowl- 
edge of  nervous  pathology),  there  is  required  in  the  head  physician,  and 
justly  expected  of  him,  a  rare  combination  of  moral  excellencies — benev- 
olence, great  patience,  self-command,  freedom  from  prejudice,  a  knowl- 
edge of  men  gained  by  actual  experience  of  the  world,  conversational 
powers,  a  decided  liking  for  his  own  special  vocation;  for  this  alone  will 
enable  him  to  overcome  its  manifold  toils  and  discouragements.  Assist- 
ant pliysicians  are  also  needed  to  aid  the  director  in  the  treatment  of  the 
patients,  the  keeping  of  the  journals  and  correspondence,  in  post-mortem 
examinations,  in  the  major  surgical  operations,  etc.     In  most  asylums,  a 


368  THERAPEUTICS. 

clergyman  is  appointed,  wliose  duty  is  to  conduct  divine  worship,  regu- 
larly to  visit  the  sick,  and  promote  recovery  by  religious  remedies.  It 
has  been  already  remarked  (p.  357)  that  in  few  cases  ought  such  mea- 
sures to  be  adopted,  and  that  all  such  visits  should  be  made  under  the 
supervision  of  the  physician,  and  only  by  his  permission.  It  would  be 
an  egregious  error  to  put  into  the  hands  of  the  laity  any  degree  of  liberty, 
however  limited,  in  the  treatment  of  the  insane.  Their  views  in  such 
matters  must  necessarily  be  very  one-sided.  Justly,  therefore,  have  some 
of  the  most  illustrious  physicians  (e.  g.,  ISTasse,  Jessen,  and  some  others) 
sought  to  curtail  more  than  ever  the  assistance  in  psychological  thera- 
peutics formerly  rendered  by  clergymen.  Frequently,  also,  we  find  a 
teacher  appointed  who,  without  any  pretensions  to  the  exercise  of  such 
psychological  means  of  cure,  is  employed  to  instruct  the  jDatients,  and 
thereby  promote  their  intellectual  culture  and  amusement. 

Two  head  attendants,  a  male  and  a  female,  should  take  charge  of  the 
lower  staff  of  servants.  Only  persons  of  considerable  bodily  strength 
should  be  engaged  as  attendants;  they  should  also  be  intelligent  and 
good-natured:  but  persons  in  every  respect  what  could  be  desired  are  sel- 
dom to  be  found.  Each  attendant  is  generally  intrusted  with  from  six 
to  ten  patients,  but  some  patients  require  the  entire  services  of  an  attend- 
ant. In  many  institutions,  these  attendants  are  selected  from  the 
brotherhood  or  sisterhood  of  some  religious  order,  a  proceeding  which, 
on  the  whole,  has  more  objections  than  recommendations.  Besides 
these,  there  are  in  asylums,  as  in  every  other  institution,  officers  spe- 
cially connected  with  the  economical  department. 

§  237.  In  order  thac  the  arrangements  in  connection  with  an  asylum, 
necessarily  always  so  complicated  m  consequence  of  the  great  number  of 
persons  and  requisites  employed,  may  go  on  with  order  and  without  con- 
fusion, there  must  be  a  written  set  of  rules  for  the  guidance  of  the  offi- 
cials; the  precise  duties  of  each  servant  should  be  definitely  and  briefly 
stated,  all  their  duties  punctually  arranged,  and  the  method  of  each  pre- 
scribed. These  rules,  judiciously  framed,  should  become  the  habit  of 
the  institution,  and  the  director  of  the  establishment  should  be  himself 
an  example  of  order,  and  thereby  exert  a  wholesome  influence  on  all  that 
are  under  him.  The  discipline  of  an  asylum  should  be  stringent,  and 
not,  under  the  specious  appearance  of  benevolence,  conducted  on  the 
laisser-aUer  principle;  punctuality  in  the  division  of  time,  the  strictest 
order,  and  the  faithful  discharge  of  duty,  must  all  be  attended  to.  All 
its  operations  should  be  so  conducted  that  every  one,  whether  healthy  or 
insane,  who  visits  or  resides  in  the  establishment,  may  be  impressed  with 
the  idea  that  it  is  conducted  on  rational  principles;  a  sense  of  tranquil- 
lity and  ease  should  pervade  the  whole,  and  the  desire  for  activity  on  the 
j)art  of  the  patients,  which  precedes  and  accompanies  every  case  of  recov- 
ery, should  be  quietly  and  moderately  indulged.  As  we  strive  to  divert 
the  mind  from  the  feeling  of  restraint  by  planting  trees  and  shrubs 
round  the  walls  that  inclose  the  grounds  of  the  institution,  familiar 
intercourse  should  not  be  too  strictly  prohibited  among  the  patients. 
We  have  seen  much  benefit  result  from  a  certain  amount  of  social  inter- 
course, in  which  the  ordinary  forms  of  general  society  were  observed. 
Indeed,  everything  that  would  estrange  the  patients  from  the  habits  of 
the  Avorld  should  be  steadily  avoided.  To  counteract  such  a  tendency, 
general  amusements,  social  gatherings,  and  walks  are  of  great  service. 
By  degrees  the  patients  should  be  thus  introduced  to  the  society  of  the 
sane.     It  has  been  sliown  above  that  from  such  a  system  of  humane  lib- 


THERAPEUTICS.  369 

eral  treatment,  mucn  more  satisfactory  results  will  flow  than  there 
would  from  a  stricter  method.  Every  gloomy,  ascetic,  barrack-like 
spirit  should  be  avoided,  and  the  great  object  of  treatment  should  be,  not 
only  to  diffuse  a  spirit  of  cheerfulness  and  reflection,  but  also  to  elicit 
and  encourage  it  on  the  part  of  the  patient. 

§  238.  Previous  to  the  admission  of  a  patient  into  a  public  asylum,  a 
special  medical  report  must  be  prepared,  indicating  the  present  state  of 
his  cusease,  its  origin,  and  development.  Many  of  the  particulars  on 
these  subjects  have  generally  to  be  furnished  by  his  friends.  Their 
statements  should  contain  an  Tinreserved  disclosure  of  everything 
important  in  the  previous  history  of  the  patient,  since  these  are  "of  the 
utmost  importance  to  the  physician.  The  medical  report  should  deal 
with  all  questions  that  bear  on  the  duration  of  the  malady;  all  etiological 
questions,  as  to  its  hereditariness,  bodily  and  mental  dispositions, 
previous  diseases — especially  of  the  nervous  system.  It  must  particularly 
recount  all  the  symptoms  of  its  gradual  or  suddo.^  outbreak,  and  the 
present  state  of  the  morbid  phenomena,  whether  the  patient  has  pre- 
viously shoAvn  any  outrageous  symptoms — details  which  are  of  essential 
service  to  the  physician  who  has  any  pretensions  to  a  comprehensive 
acquaintance  with  insanity.  When  once  it  is  determined  to  remove  him 
to  an  asylum,  the  patient  should  be  informed  of  the  resolution;  if  he 
obstinately  refuses  to  go,  it  is  much  better  to  convey  him  by  force'  than 
to  lure  him  in  by  artifice  {e.  g.,  by  telling  him  he  is  going  on  a  pleasure 
excursion).  Such  a  plan  exasperates  him  to  an  intense  degree,  and  pre- 
vents for  a  long  time  that  confidence  in  the  institution  which  is  so 
essential  to  his  welfare. 

The  admission  of  individual  patients  into  Government  asylums, 
unless  in  urgent  cases,  depends  very  much  on  the  approval  of  the 
Government  authorities,  which  in  turn*  is  regulated  by  the  opinion  of 
the  directing  physician.  In  order  to  facilitate  the  admission  of  new 
cases,  the  forms  of  procedure  should  be  as  simple  and  expeditious  as 
possible.  The  dismissal  of  patients  chiefly  depends  upon  the  order  of 
the  director.  At  first  it  should  invariably  be  provisional  or  experimental. 
Thus,  on  the  first  indications  of  relapse,  it  will  be  easy  to  bring  the 
patient  back  to  the  asylum.  During  this  temporary  dismissal,  the 
patient's  private  physician  should  furnish  an  occasional  report  of  the 
state  of  his  health.  Should  the  convalescence  continue  during  a 
sufficient  period,  varying  from  at  least  one  to  two  years,  the  patient  may 
then,  for  the  first  time,  be  permitted  to  quit  all  connection  with  the 
asylum.  Free  societies  in  aid  of  needy  convalescents  have,  in  many 
places,  been  attended  with  most  happy  results. 

§  239.  In  addition  to  public  asylums  we  have  to  speak  also  of  private 
institutions.  _  This  latter  class  in  a  great  measure  supplies  the  deficiency 
that  is  felt  in  •  countries  where  the  interests  of  the  insane  receive  no 
attention  from  Government,  or  where  the  Government  asylums  are 
inadequate  to  the  accommodation  of  all  lunatics.  Their  chief  use,  how- 
ever, is  for  patients  belonging  to  the  wealthier  and  the  aristocratic 
classes  of  society,  who  would  not  be  satisfied  with  the  ordinary  public 
asylums.  Their  importance  has  in  later  times  greatly  inci-eased,  and  is 
daily  becoming  greater.  The  State  should  place  these  institutions  in  the 
charge  of  scientific  physicians;  they  ought  never  to  be  committed  to  the 
care  of  laymen,  surgeons,  and  such  like;   and  the  directors  should  be 

'  No  restraint  is  the  universal  rule  nowadays  in  well-regulated  asylums. 


370 


THERAPEUTICS. 


required  to  furnish  sufficient  evidence  of  tlieir  ability  to  treat  insanity, 
namely,  a  sufficient  a-cquaintance  with  that  special  branch  of  study  and  a 
complete  knowledge  of  its  practice.  Such  abuses  and  scandals  as  have 
occurred  in  some  English  private  institutions  should  be  rendered  quite 
impossible  in  all  cases,  although  cases  of  a  similar  kind  have  never  even 
been  suspected  in  Germany. 

Another  plan  than  that  of  asylums  has  been  followed  in  some  places 
for  the  maintenance  and  employment  of  the  insane.  A  colony  of  insane 
has  been  formed  in  the  remarkable  Belgian  village  of  Gheel,  in  which, 
for  several  hundreds  of  years  past,  lunatics  have  lived  together  with  the 
inhabitants,  and  even  resided  in  their  families.  In  former  times,  people 
frequently  resorted  thither  to  supplicate  the  aid  of  Dymphne,  the  patron 
saint  of  the  insane,  although  people  are  seldom  in  the  habit  now  of  con- 
sulting her  oracle.  Repeated  attempts  have  recently  been  made  to  establish 
some  degree  of  regularity  and  system  among  this  settlement  of  lunatics. 
Out  of  a  population  of  about  9,000,  it  has  from  900  to  1,000  inhabitants 
who  are  insane.  In  the  year  1850,  it  was  sought  to  establish  an  admin- 
istration for  regulating  the  habits  of  the  people  and  to  introduce  some 
reforms.  But,  according  to  Parigot,'  these  attempts  generally  met  with 
little  success.  The  lunatics  enjoy  an  amount  of  pleasure  and  freedom 
which  could  never  be  permitted  them  in  an  asylum.  All  wlio  are 
capable  of  it  share  in  the  mechanical  or  agricultural  em2)loyments  of  the 
sane.  The  treatment  in  the  main  is  very  mild,  and  restraint  is  never 
made  use  of  without  previously  consulting  a  physician.  Suicide  is  rare, 
and  the  general  physical  health  so  good,  that  in  1838  two  of  the  patients 
reached  upwards  of  100  years  of  age.  Owing  to  the  peculiar  situation  of 
Gheel,  escape  by  the  patients  is  difficult;  it  is  enclosed  by  moors,  and  is 
several  leagues  distant  from  other  villages.  With  all  its  advantages  it 
has  undoubted  drawbacks,  and  there  has  recently  been  published  such  an 
amount  of  literature  of  a  polemical  kind,  furnished  by  critics  and  visitors 
of  Gheel,  that,  although  the  majority  are  in  favor  of  this  lunatic-colony, 
they  are  obliged  to  admit  it  has  serious  defects.  But  the  experiment  at 
Gheel  has  proved^  that  the  greater  number  of  insane  do  not  require  the 
confinement  of  an  asylum;  that  many  of  them  can  safely  be  trusted  with 
more  liberty  than  these  institutions  allow;  and  that  association  in  the 
family  life  is  very  beneficial  to  many  insane  patients.  Tlie  case  of  Gheel 
has  suggested  the  question  whether  similar  colonies  might  not  be  estab- 
lished in  other  places,  and  the  evils  resulting  from  the  overcrowding  of 
lunatic  asylums  thereby  removed.  In  England  and  Germany,  an  exact 
imitation  of  Gheel  has  been  recommended;  it  was  recently  proposed  to 
assemble  a  number  of  lunatics  within  a  village  in  the  immediate  vicinity 
of  a  Government  asylum,  so  that  it  might  maintain  a  certain  relation  to 
them.  The  difficulties  in  the  way  of  adopting  this  plan,  which  have  been 
collected  and  clearly  set  down  by  W.  Jessen,^  have  not  yet  been 
surmounted.  Still,  however,  I  continue  in  the  belief  that  the  day  will 
come  when  the  means  and  method  will  be  discovered  by  which  the 
problem  of  a  lunatic  colony,  and  thus  the  question  of  the  care  and  treat- 
ment of  all  classes  of  the  insane,  will  be  finally  solved. 

1  '  Journ.  de  Med.  de  Bruxelles,'  1859,  p.  464. 

"^  Roller,  'Ztschr.  fur  Psych.,'  xv.,  1858,  p.  420. 

3  Deutsche  Clinik,  1858,  *  Ztschr.  f.  Psych.,'  xvi.,  p.  42. 


INDEX. 


371 


I  ]^  D  E  X 


Abdominal    disease  causing    insanity, 
.     137 
Abdominal  organs,  affections  of,  in  the 

insane,  315 
Age,  influence  of,  on  insanity,  100 
Alcohol,    effects    of,    compared    with 

mania,  218 

—  in  treatment  of  insanity,  340 
Anaesthesia  in  insanity,  57 
Anger,  impulsive  fits  of.  190 
Anxiety  a  cause  of  insanity,  116 
Apoplexy  and  insanity,  123 
Appetite,  increase  of,  in  mania,  203 
Arachnoid,  alterations  in,  in  insanitv, 

296 
Arteries,  disease  of,  a  cause  of  insanity, 
137 

—  of  brain,  condition  of,  in  insanit}-, 
295 

Asylums,  advantages  of,  331 

—  authorities  on,  365 

—  for  idiots,  367 

—  history  of,  358 

—  statistics  of  recoveries  in,  361 
Aura  in  insanity,  56 

Aztec  type  of  idiocy,  266 

Baillarger,  case  of  melancholia,  175 
Baths  in  insanity.  337 
Bergmann,  case  of  insanity,  65 
Berlyn,  a  case  of  hypochondriasis,  154 
Bierre,  use  of  baths  in  insanity,  337 
Blood  diseases  in  the  insane,  309 
Boismont,  case  of  insanity  after  fright, 

Brachet,  case  of  hypochondriasis,  153 
Brain  and  membranes,  pathology  of,  in 
insanity,  290 

—  anterior  commissure  of,  12 

V  —  condition  of,    in  general  paralysis, 

—  cortical  substance  of,  function  of,  17 
v^  —  deficiency  of  parts  of,  251 

—  gray  substance  of,  anatomy  of,  9 
V  —  gray  substance  of,  in  idiots,  254 

«^ —  hypertrophy  of  connective  tissue  of, 
253 

—  method  of  examining,  in  disease,  15 
'"  —  smallness  of,  in  idiocy,  248 

V —  substance,  changes  in,   in  insanity, 
301  ^ 

—  unequal  development  of,  249 


295  - 
hypochondriasis, 

309 


Brain,  white  substance  of,  anatomy  of. 

Bright,  case  of  hallucinations,  69 

Camphor  in  insanity,  341 
Cerebellum,  anatomy  of,  13 

—  changes  in,  in  insanity,  304  • 
Cerebral  centres,  changes  in,  in  insan- 
ity, 303 

—  substance,  changes  in,  in  insanity, 
300 

—  vessels  in  insanity, 
Charcellay,   case  of 

155 
Cholera  in  the  insane, 

—  insanity  after,  129 
Civilization,  progress  of,  and  insanity, 

97 
Cleptomania,  206 
Cold  in  treatment  of  insanity,  336 
Conolly  on  treatment  of  the  insane,  348 
Corpora  quadrigemina  in  relation  to 

sight,  14 
Corpus  callosum,  absence  of,  251 

—  callosum,  cerebral  expansion  of,  12 
Cranium,  alterations  in,  in  insanity,  294 

—  alterations  in,  in  idiocy,  253 
Cretinism  a  form  of  idiocy,  244,  2'66 

—  absence  of  iodine  a  cause  of,  273 

—  atrophy  of  spinal  cord  in,  250 

—  endemic,  268 

—  hereditary,  273 

—  humidity  a  cause  of,  272 

—  nature  of  soil  a  cause  of,  272 

—  nature  of  water  a  cause  of,  273 
Crisis  in  insanity,  324 

Deafness,   peripheral,   followed  by  in- 
sanity, 125 
DeUrium,  acute,  form  of  mania,  209 

—  in  insanity,  50 

—  of  fever  analogous  to  insanity  79 

—  rhyming,  199 

—  sensorial,  59 

—  tremens,  symptoms  of,  209 
Delusions  not  necessary  to  insanity.  83 
Dementia,  226 

—  apathetic,  242 

—  cases  of,  218,  220,  226,  242 

—  defined,  240 

—  paralytic,  changes  in,  307 

—  partial,  with  exaltation,  194 

—  with  epilepsy,  286 


y 


372 


INDEX. 


Demonomania,  cases  of,  169 

V  Diagnosis  of  mental  disease,  80 
Digitalis  in  mania,  339 
Dreaming,  insanity  analogous  to,  76 
Dreams,  sensation  of  flying  in,  57 
Drunkenness  a  cause  of  insanity,  119 
Dumbness,  idiotic,  260 
Dysentery  in  the  insane,  310 

*^  Earle,  statistics  of  insanity,  209 
Ecstasy  in  insanity,  59 
Education,   influence  of,  on  insanity, 

110 
Electricity,    influence    of,    in  general 

paralysis,  279 
Ellis,  cases  of  insanity,  357 

—  on  onanism  as  a  cause  of  insanity, 

100 

Emotional  irritability,  46 

Emotions,  analysis  of,  37 

Emphysema  a  cause  of  insanity,  137 
.Epilepsy    a  complication   of   insanity, 

285 
^ —  and  insanitj',  123 

—  replaced  by  luania,  208 
Erlenmeier,  a  case  of  idiocy,  247 

V  Esquu'ol,  atrophy  of  optjc  nerves  with 

hallucinations,  61 

—  case  of  attempted  suicide,  182 

—  case  of  hallucination,  70 

—  case  of  mania,  208 

—  case  of  monomania,  220 

—  removal  of  hallucinations  by  cover- 
ing the  eyes,  02 

—  on  removal  of  the  insane  to  asvlums, 
332 

—  suicides  mentally  diseased,  177 

Exaltation,  states  of  mental,  193 
Falret  on  folie  circulaire,  163 
Ferrus,  treatment  of  ci'iminals,  104 
^'  Fevers  causing  insanity,  127 
Flemniing,   cases  of  insanity,   52,   128, 
134 

—  on  use  of  emetics  in  insanity,  340 
Focke,  case  of  insanity,  128 

—  statistics  of  recoveries  in  asylums, 
361 

Foville,  structure  of  brain,  13 
Fright  a  cause  of  insanity,  116 

v/ Genital  organs,  disease  of,  a  cause  erf 
insanity,  139 

Georget,  insanity  witn  homicidal  ten- 
dency, 187 

Gheel,  colony  of  insane  at,  370 

Goitre,  see  Cretinism,  268 

Gratiolet  on  auditory  root,  14 

—  on  hallucinations  of  sight,  68 

—  on  sensation  of  flying  in  dreams,  57 
Guillot  on  auditory  root,  14 
Guislain,    analogy   between   dreaming 

and  insanity,  77 

—  case  of  idiocy,  247 

—  case  of  insanity  (recovery),  344 

—  case  of  melancholia,  183,  189,  312 


Guislain  on  dancing  parties  in  insanity, 

347 
Guy,  case  of  melancholia  with  desire  to 

murder,  184 

Hasmatoma  of  the  ear,  310 
Hallucinations  in  chronic  mania,  232 

—  in  insanity,  56-72 

—  in  sane  persons,  65 

—  of  sight  with  atrophy  of  optic  nerves, 
61 

Head,  injuries  to,  and  insanity,  123 
Hearing^  hallucinations  of.  69 

—  hallucinations  of,  in  a  case  of  mania, 
236 

Heart,  affections  of,  in  the  insane,  314 

—  affections  of,  a  cause  of  insanity,  136 
Henle,  memoiy  in  the  senses,  23 

\  Hereditary  insanity,  106 
Heschl  on  porencephalus,  250 
Holland,  duality  of  mind,  18 
Home  sickness,  form  of  melancholia, 
171 

\ Hydrocephalus  a  cause  of  idiocy,  252 

—  chronicus  in  the  insane,  303 
Hydrocyanic  acid  in  mania,  339 
Hyclropathy  in  insanity,  337 

''■  Hypertemia  of  brain  a  cause  of  insanity, 
115 
Hypochondriasis,  147 

—  cases  of,  152,  155 

—  mode  of  origin,  151 

—  symptoms  of,  148 
Hysteria,  126 

Ideas,  incoherence  of,  199 

Idiocy,  anomalies  of  cranium  in,  254 

—  anomalies  of  desires,  etc..  in,  261 

—  anomalies  of  senses  in,  259-263 

—  apathetic,  265 

—  causes  of.  246 

—  course  of.  267 

—  dumbness  in,  260 

—  excited,  265 

—  gray  substance  of  brain  in,  254 

—  hypei-trophy  of  brain  in,  253 

—  meaning  of  term,  244 

—  varieties  of,  265 
Idiots,  asylums  for,  367 

—  classecl  according  to  speech,  260 
Illusions  and  hallucinations  distinct,  59 
Impressible  explained,  38 
Imprisonment,  influence  of,  on  insan- 

ity,  104 
Incoherence  of  ideas  in  mania,  200 

—  temporary,  in  health,  48 

Insane,   affections    of    the    abdominal 
organs  in  the,  315 

—  affections  of  the  heart  in  the,  314 

—  blood  diseases  in  the,  309 

—  cholera  in  the,  309 

—  colony  of,  at  Gheel,  370 

—  criminal  acts  of  the,  on,  54 

—  dysentery  in  the,  310 

—  haematoma  of  the  ear  in  the,  310 

—  physical  treatment  of  tlie,  333 

—  removal  of  the,  to  asylums,  331 


INDEX. 


373 


Insane,  respiratory  diseases  in  the,  311 

—  statistics  of  mortality  of  tlie,  317 

—  typhus  fever  in  the.  309 
Insanity,  see  Melancholia,  etc, 

—  acute,  changes  in,  306 

—  after  cholera,  129 

—  after  strong  smell,  125 

—  analogies  of,  75 

—  and  civilization,  97 

—  and  intoxication,  87 

—  and  tjq^hus  fever,  87 

—  aura  m,  56 

—  blood  diseases  in,  309 

—  cases  of,  54.  56,  57,  60,  62,  68,  70,  71, 
73,  77,  79,  128,  130,  133,  149,  152,  165, 
160,  175,  181,  184,  185,  187,  189,  190. 
204,  206,  211,  219,  226,  233,  242,  312, 
344,  357 

—  causes  of,  89 

—  changes  in  arachnoid  in,  296 

—  changes  in  cerebral  centres  in,  303 

—  changes  in  cerebral  substance  in, 
300 

—  changes  in  cranium  in,  294 

—  changes  in  great  vessels  of  brain  in, 
295 

—  changes  in  pia-mater  in,  298 

—  chronic,  changes  in.  306 

—  complications  of,  277 

—  complicated  with  epilepsy,  285 

—  compulsory  feeding  in,  355 

—  delusions  not  necessary  to,  83 

—  emphysema  a  cause  of,  137 
--.■(umsof,  144,  299 

—  feigned,  85 

—  following  peripheral  irritation,  125 

—  from  abdominal  disease,  137 

—  from  disease  of  genital  organs,  139 

—  from  drunkenness,  119 

—  from  fever,  127 

—  from  heart  disease,  136 

—  from  intestinal  worms,  138 

—  from  other  nervous  diseases,  123 

—  from  pregnancy,  etc.,  141 

—  general  diagnosis  of,  80 

—  general  paralysis  in,  278 

—  hereditary  predisposition  to,  106 

—  hyperaemia  of  brain  a  cause  of,  115 

—  hysterical,  126 

—  in  course  of  pneumonia,  130 

—  in  different  sexes,  98 

—  influence  of  age  on,  100 

—  influence  of  education  on,  110 

—  influence  of  imprisonment  on,  103 

—  influence  of  marriage  on,  99 

—  influence  of  moon  on,  105 

—  influence  of  seasons  on,  105 

—  influence  of  social  position  on,  103 

—  mental  constitution  a  cause  of,  111 

—  method  of  examining  brain  in,  15 

—  of  the  intellect,  50 

—  opium  a  cause  of,  121 

—  pellagrous,  136 

—  periodic,  129 

—  physical  causes  of,  122 

—  prognosis  and  treatment  of,  317 


Insanity,  psychical  causes  of,  115 

—  sexual  excess  a  cause  of,  122 

—  sketch  of  course  of,  36 

—  statistics  of,  in  different  nations,  95 

—  suicide,  attempts  at,  in,  181 

—  therapeutics  of.  326 

—  tobacco  a  cause  of,  121 

—  venesection  in,  334 

—  with  apoplexy,  123 

—  with  chronic  diseases,  134 

—  with  disease  of  arteries,  137 

—  with  epilepsy,  123 

—  with  injury  to  head.  123 

—  with  rheumatism,  132 

—  with  syphilis,  134 

—  with  tendency  to  murder,  183 

—  with  tuberculosis,  135 
Intellect,  weakness  of,  in  idiocy,  245 
Intermittent  fever  followed  by  insanity, 

128 
Intoxication  a  cause  of  insanity.  119 

—  and  mania  compared,  218 

—  diagnosed  from  insanity,  87 
Iodine,  absence  of,  a  cause  of  cretin- 
ism, 273 

Jacobi,  ague  in  place  of  insanity,  129 

—  cases  of  mania,  206,  211 

—  case  of  monomania,  219 

—  case  of  recovery  from  melancholia, 
165 

—  on  cleptomania,  55 

—  on  mania,  198 

—  on  use  of  cold  in  insanity,  336 

—  on  use  of  tartar  emetic  ointment  in 
mania,  337 

Jessen  on  colonies  of  insane,  370 

Kerner,  case  of  insanity,  170 
Kidneys,  disease  of,  a  cause  of  insanity, 

138 
Kieser,  case  of  hallucination,  70 

Lactation  a  cause  of  insanity,  143 
Lallemand,  melancholia  with  desire  to 
murder,  184 

—  recovery  from  melancholia,  167 

—  sexual  functions  in  insanity,  139 
Langermann,  reform  in  treatment  of  in- 
sane, 358 

Lautard,  case  of  hereditary  transmis- 
sion of  insanity,  108 

Lead-poisoning,  influence  of,  on  brain, 
121 

Lelut  on  hallucinations,  63 

Leuret,  case  of  chronic  mania,  236 

—  case  of  deinentia,  242 

—  case  of  monomania,  221 

—  cases  of  lyranthropia,  56 

—  on  suppression  of  hallucinations,  etc., 

344 
Longet,  cases  of  insanity,  3 
Lung  diseases  in  the  insane,  311 
Lycanthropia,  56 


374 


INDEX. 


Magnesia  in  water  a  cause  of  cretinism, 

273 
Mania  and  intoxication  compared,  218 

—  anomalies  of  disposition,  etc.,  in,  196 

—  anomalies  of  intellect  in,  198 

—  anomalies  of  senses  and  movement 
in,  201 

—  cases  of,  206-209 

—  chronic,  226 

—  chronic,  anomalies  of  desires,  etc., 
in,  228 

—  chronic,  anomalies  of  the  senses  in, 
232 

—  chronic,  anomalies  of  thought  in,  230 

—  chronic,  cases  of,  233-239 

—  chronic,  defined,  228 

—  incoherence  of  ideas  in.  200 

—  incomplete,  cases  of.  211 

—  incomplete,  symptoms,  210 

—  invasion  and  course  of,  210 

—  period  of  incubation  of,  196 

—  periodical,  204 

—  prognosis  of,  205 

—  sudden  recovery  in,  204 

—  two  forms  of,  192 

—  without  delirium,  212 

Marc,  case  of  attempted  suicide,  182 

—  case  of  insanity,  185 

— •  case  of  monomania,  223 
Marriage,  influence  of.  on  insanity,  99 
Masturbation  a  cause  of  insanity,  122 
Meding,  case  of  dementia,  226 
Medulla  oblongata,  inequality  of,  250 
Melancholia,  146 

—  cases  of,  219,  220,  312 

—  cases  of  (recovery),  165-167 

—  changes  in,  306 

—  course  of,  163 

—  metamorphosis,  171 
— •  religiosa,  168 

—  religiosa,  cases  of,  169 
— -simple,  156 

—  symptoms  of,  156,  163 

—  with  destructive  tendencies,  176 

—  with  persistent  excitement,  190 
— ■  with  stupor,  172 

— ■  with  tendency  to  murder,  183 
Memory,  affections  of,  48 

—  process  of,  23 

Mende,  a  case  of  attempted  suicide,  181 

—  melancholia,  with  attempt  to  mur- 
der, 185 

Meningitis,  symptoms  of,  88 
Menstruation,  influence  of,  on  sanity, 

140 
Mental  constitution  causa  of  insanity, 

111 

—  disease,  forms  of,  144 

—  disease,  pathology  of,  289 

—  disease,  prognosis  and  treatment  of, 
317 

—  disorders  in  idiocy,  259 

—  exaltation,  states  of,  192 

—  processes,  observations  on,  17 

—  weakness,  states  of,  225 
Michea,  cases  of  melancholia,  58 


Microcephalism,  248 
Microcephalics,  cases,  248 
Mildner,  case  of  transitory  mania,   204 
Moon,  influence  of,  on  insanity,  105 
Monomania,  anomalies,  of  desires,  etc., 
in,  213 

—  anomalies  of  intelligence,  214 

—  anomalies  of  senses,  etc. ,  in,  216 

—  bad  term,  52 

—  cases  of,  219,  223,  233        * 

—  defined,  213 

—  distinguished  from  mania,  192 

—  form  of  chronic  mania,  228 

—  passing  into  dementia,  242 
Moral  treatment  of  the  insane,  342 
Morel,  case  of  simulated  suicide,  181 
Morphia,  in  mania,  338 

Mortality  of  the  insane,  statistics  of,  317 
Movement,  anomalies  of,  in  idiocy,  263 

—  anomalies  of,  in  mania,  201 

—  anomalies  of,  in  monomania,  216 

—  disorders  of,  73 

Miiller  on  hallucinations.  67 

Murderous  impulse  with  melancholia, 
183 

Muscular  activity,  tendency  to,  in  in- 
sanity, 54 

Narcotics  in  mania,  338 
Nerve,  auditory,  cerebral  expansion  of, 
12 

—  olfactory,  cerebral  expansion  of,  15 

—  optic,  cerebral  expansion  of,  12 
Neuman  on  use  of  Straight-jacket  in 

mania,  349 
Neuroses  followed  by  insanity,  125 
Niepce,   a  case  of  hydrophobia  in  an, 

idiot,  260 
Nymphomania,  206 
Nystagmus  in  insanity,  74 

Opium  a  cause  of  insanity,  121 
Ovaries,  disease  of.  a  cause  of  insanity, 
141 

Pain  causing  insanity,  126 

—  mental,  25 

Paralysis,  general,  with  insanity,  277 

Pathology  of  mental  disease,  289 

Pellagrous  insanity,  136 

Perfect,  use  of  camphor  in  insanity, 
341 

Peripheral  irritation  followed  by  in- 
sanity, 125 

Personality,  renunciation  of,  56 

Pia-mater,  alterations  in,  in  insanity, 
298 

Pineal  gland,  affections  of,  in  insanity, 
304 

Pinel,  case  of  immoderate  anger,  190 

—  case  of  suicide,  182 

—  on  use  of  restraint  in  insanity,  349 

—  reform  in  treatment  of  the  insane, 
358 

Pituitary  gland  in  insanity,  304 
Pneumonia,  insanity  in  course  of,  130 


INDEX. 


375 


Porencephalus,  250 
Pregnancy  a  cause  of  insanity,  141 
Prognosis  of  insanity  317 
Psychical  causes  of  insanity,  115 
Puerperal  condition  a  cause  of  insanity, 

141 
Pupils,   state  of,  in  general  paralysis, 

280 

—  great    contraction    of,  unfavorable, 
74 

Pyromania,  189 

Reason,  analysis  of  process  of,  41 

Recovery,  statistics  of,  in  Germany,  332 

Reflection,  analysis  of,  32 

ReU,  case  of  insanity,  357 

Religion  an   aid  in  treatment  of  the 

insane,  347 
Renaudin,  case  of  anaesthesia,  58 
Restraint  in  treatment  of  insanity,  348 
Rheumatism  a  cause  of  insanity,  132 
Rochoux,  a  case  of  anaesthesia  in  a 

maniac,  57 
Romberg,  case  of  mania,  100 

Salomon,  statistics  of  suicides  in  Bel- 
gium, 179 
Scliiff ,  functions  of  spinal  marrow,  2 
Schlager  on  concussion  as  a  cause  of 
insanity,  124 

—  suicide  among  melancholies,  180 
Seasons,  influence  of,  on  insanity,  105 
Sensation,  anomalies  of,  in  mania,  202 

—  disorders  of,  55 

Senses,  anomalies  of,  in  chronic  mania, 
232  k 

—  anomalies  of,  in  idiocy,  259,  263 

—  anomalies  of,  in  mania,  201 

—  anomalies  of,  in  monomania,  216 

—  hallucinations,  etc.,  of  several,  com- 
bined, 73 

Sentiment,  anomalies  of,  45 
Sexes,  insanity  in  different,  98 
Sexual  excesses  a  cause  of  insanity,  122 

—  instinct,  increase  of,  in  mania,  202 
Shock  a  cause  of  insanity,  116 
Sight,  hallucinations  of,  68 
Sinogowitz,  a  case  of  chronic  mania. 

233 

—  case  of  illusions  of  smell,  71 
Sleep,  troubled,  in  mania,  202 
Smell,  hallucinations  of,  71 

—  impression  of,  followed  by  mania, 
125,  208 

Snell  on  anaesthesia  in  insanity,  58 
Speech,  absence  of,  in  idiocy,  260 
Spinal  cord,  atrophy  of,  in  cretinism, 
250 

—  cord,  cerebral  prolongations,  13 

—  cord,  functions  of,  17 

—  neuroses  followed  by  insanity  125 


Statistics  of  age  of  the  insane,  101 

—  of  drunkenness  as  a  cause  of  insan- 
ity, 120 

—  of  nationalitj^  of  insanity,  95 

—  of  sex  as  a  cause  of  insanity,  98 
— of  social  position  of  the  insane,  103 
Stiedenorth,  brain  affected  in  insanity. 

Strangulation,  attempt  at,  followed  by 

dementia,  226 
Suicidal  tendencies  with  melancholia, 

177 
Suicide,  simulated,  in  insanity  (cases), 

181 
Syphilis  a  cause  of  insanity,  134 

Tartar  emetic  ointment  in  mania,  337 
Taste,  hallucinations  of,  71 
Temperature  in  cases  of  mania  with 
pneumonia,  130 

—  in  general  paralysis,  282 
Therapeutics  of  insanity,  326 
Thought,  anomalies  of,  47,  230 
Thurnam,  statistics  of  insanity,  101 
Tobacco,  influence  of,  on  sanity,  121 

—  in  insanity,  340 

Tongue,  paralysis  of,  in  insanity,  278 
Treatment  modified  according  to  case, 
351 

—  physical,  of  the  insane,  333 
Tuberculosis  a  cause  of  insanity,  135 
Tyerman,  autopsies  at  Colney  Hatch, 

137 
Typhus  fever  diagnosed  from  insanity, 
87 

—  fever  in  the  insane,  309 

—  followed  by  insanity,  127 

Uterus,  disease  of,  a  cause  of  insanity, 
141 

Velten,  case  of  mania,  207 

Venesection  in  insanity,  334 

Ventricles  of  brain,  changes  in,  in  in- 
sanity, 303 

Voppel,  accounts  of  autopsies  in  Colditz 
Asylum,  136 

Wigan  on  quality  of  mind,  18 
Will,  analysis  of  the,  30 

—  anomalies  of  the,  53 
Willis,  case  of  insanity,  137 
Winslow,    case  of  attempted  suicide, 

178 
Worms,  intestinal,  a  cause  of  insanity, 
138 

Zeller  on  cases  of  mania,  54 

—  on  Guislain's  Phrenopathie,  48 

—  use  of  cold  in  insanity,  336 


10 


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